Beatriz
The three grey concrete buildings of the medical school looked just as drab as they had twenty years ago but seemed less imposing. Now Helen realized that the buildings were only six stories tall. They were arranged around a courtyard which faced the traffic on a busy street in front. The courtyard had tables and benches but no plants or trees, nothing to diminish the noise and heat coming from the cars waiting at the corner for the red light to change.
Helen remembered sitting at one of the cement tables every day during her lunch break between classes and eating a package of bright orange peanut-butter crackers from the vending machine. Her meager meals had remained the same for all four years of med school. It was one less thing to have to think about.
She never expected to return to the South, a place of unpleasant memories, but here she was, waiting for a job interview. She wanted to live closer to her father because his dementia had become more severe after her mother’s death. It seemed cruel to relocate him to New Mexico, where she had settled, so she moved herself back despite her misgivings.
Helen had a classmate who was a faculty member at the medical university. When she mentioned to him that she wanted to move back, he said he’d heard about a new opening in the obstetrics department.
The department chairman was expanding a prenatal care clinic that provided services for undocumented Latina women, and he needed a doctor to supervise the midwives who staffed it. Helen had taken care of many Spanish speakers in New Mexico, so the job sounded like a good fit.
She was going to miss the New Mexico clinic where she’d worked for the past seven years. The patients loved coming to the old converted schoolhouse with its bright colors and beautiful garden. If they couldn’t pay for their visits, many of the doctors would see them for free. That meant the clinic kitchen was often full of delicious dishes the patients brought as a sign of thanks.
Helen checked her watch, walked through the familiar university doors, and took the elevator to the obstetrics floor. The decor had improved considerably since her student days. The secretary behind the sleek wooden counter took her name and motioned for her to wait in one of the embroidered chairs arranged around a large Persian rug. Helen picked up a university magazine from the glass table and absentmindedly thumbed through it.
She wondered if the hospital’s practices had become more structured and responsible in the twenty years since she’d been a medical student. In those days, the third-year students were pushed out on the wards to do scut work, like drawing blood and starting IVs, with very little instruction from the senior staff. And if you proved to be good at scut work, you were assigned even more difficult tasks for which you had no training.
It wasn’t long before the department chairman, Dr Vance, came out to greet her with a big smile. He had been on staff as an attending physician during her time as a student. She was not surprised to find that he had aged well and still walked with the same swagger.
They went into his office, and Helen sat across from him at his desk. He started with a perfunctory welcome and then got to the point.
“Medicaid reimbursements for poor patients have increased so much around here that the private attendings are competing to have them as patients.”
She nodded approvingly.
“No, that’s not good, because it means that we have fewer patients for the residents and medical students to learn on.”
When she was a fourth-year medical student, it was so busy that Helen was often left delivering babies on her own with no backup physician in the room. She felt pretty sure that having fewer patients would mean more supervision and better care, but she stayed quiet.
Dr Vance continued, “Three of our midwives have been running a prenatal care clinic for undocumented women for the past five years. It’s so small I’d practically forgotten about it until I realized it would provide all the charity patients we could ever need. More and more migrant laborers are flocking here because of all the new construction jobs as the city expands, and now they’re bringing their wives. No other doctors in town want to take care of them, so this clinic has gotten popular. There’ll never be a shortage of teaching cases for the medical students and residents, and we’ll be doing the patients a great service.”
He winked, “Even better, they’re here illegally, so they hardly ever sue.”
Helen felt unsure how to respond, so she changed the conversation to give herself a few minutes to think. She feigned interest in a picture of Dr. Vance and his family aboard a yacht and asked questions about the doctors she remembered from her medical student days.
While he talked, she weighed the options. She was uncomfortable with the premise of using immigrants as training cases but thought it was possible she could help the women by giving them good prenatal care.
Dr. Vance glanced at the clock on his desk and concluded the interview, “With your years of experience in New Mexico and your Spanish, we thought you’d be an excellent fit for the job.”
Helen smiled. Since this job had fallen into her lap, she decided not to look for another. She needed to help her father as soon as she could, without burdening herself with a lengthy job search, so she decided to take it.
* * *
The clinic was on a busy highway across the street from a defunct shopping mall. The head midwife, Naomi, welcomed Helen warmly. She escorted her into an office with a large desk and a framed painting on the wall of an indigenous woman with her arms full of lilies.
Naomi motioned for Helen to sit across from her at the desk and handed her a sheet of paper. She said, “Our electronic medical record is pretty straightforward. I’ve written down the basics for you.”
Helen glanced down and replied, “Thanks. I was a bit worried about learning yet another new EMR with all their quirks and differences.”
Naomi continued, “I know you speak some Spanish, but should you ever need help, there are always three native speakers working at the front.”
Helen smiled, “That’s a relief, too.”
“You’ll meet the other midwives tomorrow. There are usually two of us on staff daily, but Patty’s out sick today. We’re really looking forward to having a doctor on site to answer all our questions. Since we’re expanding the patient base, there are bound to be more complicated cases. So, do you want to go ahead and start seeing patients today? I can show you our exam rooms.”
Helen stood up, “Since you’re short one midwife, I may as well get started.”
Her first few patients were straightforward, and she managed to complete the prenatal checkups without needing a translator or any help with the computer. But after her quick bag lunch of grapefruit and almonds, a more challenging patient arrived.
Beatriz didn’t seem to understand very much of what Helen said when she tried to converse in Spanish, and Helen couldn’t understand Beatriz, either. Worse, Beatriz was upset and kept wiping tears from her eyes.
Helen went to get some help at the front and was relieved that a young woman named Marta was available. Marta told Helen that Beatriz was originally from Brazil and spoke only Portuguese. She smiled and said she could translate for Helen, because she had picked up Portuguese during her many summers in Rio visiting an aunt who lived there.
Beatriz brightened up a little when Marta came into the room. They had an extended conversation with phrases that sounded like a mash-up of Spanish and French. Marta said there were quite a few Brazilian patients but assured Helen she’d always be there to help.
It turned out that Beatriz’s father had died only a few days before. It had been six years since she’d seen her father or her mother in her hometown in northeastern Brazil. She hadn’t been able to return home in all that time because of the difficulty of getting back across the border and into the United States. She desperately wanted to be at her father’s funeral, but her husband was too concerned about the expense and her safety to let her make the trip.
Beatriz told Marta that her husband worried about everything now that they’d finally gotten pregnant after trying for so many years. He was even nervous about her friend driving her to the clinic because there was so much traffic on the highway to get there.
Helen gave her condolences and asked Marta to make sure the patient still wanted to have an exam today. When Beatriz nodded yes, Marta gave her a paper gown. While she was changing, Helen went back to her computer and reviewed the prenatal record in more detail.
At twenty-eight weeks, Beatriz, aged 38, was more than halfway through her first pregnancy. All her screening prenatal labs were fine, her ultrasound results were consistent with her dates, and she’d had a recent normal glucose tolerance test, ruling out diabetes. Although she was heavy, she hadn’t put on too much additional weight during her pregnancy to date.
When Helen returned to the exam room, Beatriz was crying again, and Marta sat beside her holding her hand. Helen gently used a measuring tape to estimate the size of the baby and listened to the fetal heart. Everything seemed fine, so she recommended a routine visit in two weeks’ time.
* * *
The next morning Dr Preston, the faculty doctor in charge of the clinic, came in for the monthly meeting. Helen was pleased to see the front staff, the nurses and the midwives all attending. First, he reminded Helen and the staff that Medicaid didn’t cover any of the prenatal care for illegal immigrants. Hospital fees for labor and delivery were a different matter, because they could be life-threatening and were covered by Emergency Medicaid.
He then grew more serious. “As you’re aware, until now, the university has only been charging a nominal fee for prenatal visits, but I’m afraid I have some bad news for the patients. It’s clear that the prices we’ve been charging won’t be enough to cover our expenses now that we’re expanding the clinic. We had a business meeting last week, and the decision was that we’re going to have to double the prenatal fees.”
There was an audible gasp from the staff.
He continued, “The price increase will go into effect immediately, so it’s going to be tough to explain the change to patients who are in the middle of their pregnancies. But it’s still much lower than what the private attendings would charge, so I hope we won’t lose too many of them.”
After the meeting, Helen sat down with the midwives and asked, “What do you think? Will most of our patients be able to pay for the visits if they’re twice the price?”
Naomi said, “Some of them will try to scrape together the money. They know it’s better to have prenatal care and, as he said, there are no cheaper alternatives. But some will stop coming in altogether for prenatal care because they can’t afford it. They’ll just accept the risks and show up at the nearest hospital when they go into labor.”
Helen said, “I guess I thought the university had a grant or some money they’d set aside to support this program fully.”
Naomi said, “Since the beginning, we’ve always run on limited funds. They hired the three of us to run this clinic, and then seemed to forget it existed. We were surprised when they hired you and said they wanted to spruce up the place.”
* * *
Later that afternoon, Helen went to see her father in the dementia unit at the nursing home. She trudged in with the poor clinic patients on her mind. She hoped the new policy had nothing to do with her hiring and the cost of her salary.
She brought her father a box of chocolate caramel turtles that they both loved when she was a child. He greedily took the box from her but was unable to remove the plastic wrapper, so she wrested the box away and did it for him. She gave him the open box, and he started eating one turtle after another.
She sat down in the chair beside the bed and waited for him to remember she was there, but it didn’t happen. When he’d finished half the box, she said, “Daddy, I don’t think you should eat all those at one time.”
She got his attention for a minute, but it was clear he didn’t recognize her. He quickly returned to pushing the crinkled paper cups around so he could find another turtle. Helen decided to let him be. Her father looked so skinny that the whole box of turtles couldn’t possibly hurt him.
* * *
When Beatriz returned to the clinic two weeks later, she had gained seven pounds and reported that the baby was moving less than usual. Helen examined her carefully. She retook her blood pressure and checked her ankles for swelling, but all seemed normal on the pre-eclampsia front. The baby’s measurement was a little on the large side, but the fetal heart looked normal on the monitor and Beatriz happily reported some kicking during the fifteen-minute test.
Beatriz told Marta that she knew she’d been eating too much since her father’s death and promised to do better now. She reached over to hold Helen’s hand and said she was glad that Helen was her doctor and would be there when her baby was born.
Helen sighed. She turned to Marta and said, “I’m afraid I won’t be there when she has the baby. I only work at the clinic, so it will be a different doctor delivering her at the hospital.”
After Marta translated, Beatriz blinked hard and lowered her eyes. Helen felt sad and guilty. She was used to delivering babies for the pregnant patients she had followed in New Mexico, but it was no longer in her job description.
* * *
Beatriz didn’t come to her next follow-up appointment. Helen tried calling her number, but it had been disconnected. Marta told Helen that after Beatriz learned about the increased fee for prenatal care during the last visit, she had motioned for her to come and sit beside her in the waiting room. Beatriz had told Marta that her husband had been laid off because he was injured doing construction work and asked if they could catch up on the prenatal care payments when he found another job.
Dr Preston hadn’t mentioned anything about payment plans at the meeting, so no one knew for sure. They had left messages for Dr Preston, but neither he nor anyone else at the university had answered their calls.
Helen went back to her office to call Dr Preston. The secretary put her through to his answering machine, so she left a message asking about the procedure for women who were unable to pay at the time of the visit. A fax on university letterhead arrived later that afternoon outlining the rules for patients who got behind with payments. After a grace period of only a month, they would be sent to collection.
Helen asked the front desk to schedule an appointment for Beatriz and to send her a letter asking her to call to confirm. Marta said Beatriz and her husband might not even be living at the same address at this point. She’d known several patients who had to move after their husbands were laid off and they ran out of money.
* * *
Two weeks later, Helen was with a patient when Beatriz came in for her scheduled appointment. Naomi examined Beatriz and caught up with Helen as soon as she was free.
“I’ve just seen Beatriz and need to talk to you in your office.”
They walked back to Helen’s office in silence and Naomi closed the door. Helen remained standing. She was much too anxious to sit down.
Naomi said, “Beatriz has gained ten pounds and her baby’s measurement is much larger than it should be. What’s worse, Beatriz told Marta that she hasn’t felt the baby moving this morning. I’ve listened with the Doppler all over her stomach, and I can’t find the fetal heart.”
Helen asked, “Is her husband here?”
Naomi said, “No, he’s back at work, so a friend brought her.”
Helen looked over at the painting of the woman with her arms full of lilies. She told Naomi to bring the ultrasound machine into Beatriz’s room and said she would meet her there. Helen went into the bathroom to gather herself, then proceeded on to the exam room.
When she got there, Beatriz was crying, and Marta sat beside her holding her hand. Helen thought, first her father dies, and now probably her baby as well.
Helen said to Marta, “Can you tell Beatriz that we want to look at the baby with the ultrasound machine? We’ll need to lay her flat so we can see better.”
Helen looked from several angles, but the ultrasound confirmed that the baby was dead. There was no movement, and the baby’s heart was still. Helen put the ultrasound probe back in its place. When she turned to rest her hand on Beatriz’s shoulder, there were tears in Helen’s eyes. Beatriz began to quietly moan, “No, no, no.”
Helen asked Marta if she could tell Beatriz that the baby had died. As a young receptionist, Marta was not the ideal person to give such a task, and it pained Helen to do so, but the news had to be delivered.
Marta did her best, but her voice broke at the end.
Beatriz shook in agony. Helen told Naomi she wanted to stay in the room with Beatriz for a while. She also asked if Naomi and Patty could see the rest of her patients for the day.
Helen sat down by the bed ready to answer any questions Beatriz might have. Marta was still on the other side holding Beatriz’ hand.
When Beatriz appeared a little calmer, Helen told Marta she needed her to translate another difficult thing, namely what was going to happen next.
Helen told Marta, “Beatriz should call her husband as soon as she can, because they have to go to the hospital this afternoon. She’ll need to stay for a few days, so she should pack her things. Once she’s admitted, they’ll start an IV and give her medication to start her labor.”
After the translation, Beatriz looked surprised and asked Marta a question.
Marta said, “She asked if she has to deliver a dead baby.”
Helen nodded, “I’m afraid so.”
* * *
The next day, Helen got a call from one of the residents at the hospital.
The resident said Beatriz had delivered a nine-and-a-half-pound stillborn early that morning. She then asked, “How did you miss her diabetes?”
Helen said, “Her screening glucose tolerance test was totally normal earlier in the pregnancy. I suppose she could have developed gestational diabetes in the last month when she was lost to follow up.”
The resident said, “The attending found it hard to believe her GTT was ever normal, because she has such a severe case now. It was definitely the cause of the baby’s death.”
Helen said, “Thanks for letting me know. I’ll look into it.”
Helen spoke to Naomi later that morning in her office. She said, “The residents called from the hospital to let me know that Beatriz had severe gestational diabetes. It was entirely out of control, and that’s why the baby died. I wonder why her screening test was normal.”
Naomi said, “I guess the Fanta we were using for the test didn’t pick it up. It must not be as good as the standard Glucola.”
Helen asked, “What? You were using Fanta instead of Glucola?”
“The women didn’t like the Glucola. We thought if we found a soft drink that was an equivalent alternative, it would make them happy. It also made the hospital happy because the Fanta was so much cheaper. Every pregnant woman needs the test, so it saved them lots of money. We did have the nutritionists at the hospital analyze it, and they thought it was fine too.”
Helen put her head in her hands, “In my twenty years doing obstetrics, I’ve never heard of anything like this before. All the scientific studies about screening for diabetes were done with Glucola.”
Naomi sighed, “It probably was a bad idea.”
Helen said, “We need to call the lab and get at least ten cases of Glucola sent to us as soon as possible. I want to rescreen all the pregnant patients when they come in no matter how far along they are. Their babies might be at risk.”
Naomi got up from her chair, “I’ll let them know.”
* * *
The front desk put through a call from Dr. Preston when Helen was eating her grapefruit and almonds for lunch at her desk.
He said, “I heard from the lab that you need ten cases of Glucola. You don’t have anywhere near that volume of patients, so I wanted to find out what was happening there.”
Helen said, “We just had a baby die because the woman had undiagnosed gestational diabetes. Her screening test was done with Fanta, not Glucola, so I want to rescreen all the prenatal patients to make sure it doesn’t happen again.”
Dr Preston said, “I’ve been briefed about this case. That patient had problems because she didn’t show up for her prenatal appointments as she should have. We don’t have the time or the money to rescreen all the patients. She’s the one outlier and she’s a noncompliant patient.”
He ended the call, and Helen was left staring into space.
This job was not one she should have taken, and she should have known it from the start. She could never find peace of mind in this cruel and unjust place and was going to have to look for another place to work.
~