Barrow, Alaska. Home of 40 mph winds, and temperatures that routinely reach 60 below zero with the wind chill. There is no daylight at all for two full months in the winter. It is the northernmost tip of continental North America, 330 miles above the Arctic Circle, and has a population of about 4000, mostly Eskimo.

      This is where I, a “Nice Jewish Girl” from New Jersey, moved after residency. I had absolutely no intention of relocating to Alaska, even when I went for an interview. But Alaska worked its magic on me, and I fell in love with the tundra. I never made a conscious decision to move. On the contrary. On my flight back to NJ, a thought popped into my head. “Great, now I have to move to Alaska.” So I did.

      Barrow, as well as the surrounding villages, can only be reached by plane. There are no roads connecting the villages to Barrow, or Barrow to the rest of Alaska. Transportation is provided by Alaska Airline jets, which run twice a day in the winter, and three times daily in the summer. The more frequent flights are for the tourists who want to claim that they have been to “the top of the world.” The tourists come mostly in the summertime, to view the midnight sun. When it is sunny all night, Barrow streets are (relatively) lively even at 2 am. In a place where the sun sets in November and doesn’t rise again until the end of January, people want to take advantage of every minute of daylight. They ride snowmobiles until the snow melts in May or June, and then switch to ride ATVs over the tundra. It is flat, and in the wintertime, white, in every direction as far as the eye can see. Barrow is perched right on the Arctic Ocean. With several miles of frozen ocean ice lining the shore, it is an excellent place for snowmobiling. The Natives ride their snowmobiles on the ice day and night, for relaxation, transportation in town, and to get to the spring whaling camps that are built every year on the edge of the sea ice.

      Samuel Simmonds Memorial Hospital provides healthcare for Barrow and six surrounding villages. The other villages have their primary care at local clinics, staffed by “health aides.” These men and women are mostly Native, many from the villages where they work. One only needs four months of training to start practicing as a Health aide. For the most part, these providers do a good job, using algorithms for medical care. At the end of each workday, the doctors in Barrow review by phone all the cases seen in the villages. The physician on call is also always available for emergent consults. A second doc is on  “backup call” in case of multicasualty disaster.  The hospital in Barrow is the only hospital with any emergency capabilities for hundreds of miles, and Samuel Simmonds is only a thirteen-bed hospital. It is staffed onsite solely by primary care physicians. At the time I was there, we had four full time doctors- one trained in med-peds, two general practitioners, and me, a family doc. There were also three mid-level practitioners. The hospital is supposed to have seven full-time doctors, but for a variety of reasons, including its remoteness, Samuel Simmonds has been running on a skeleton staff for many years.

 

 

The Hospital in Barrow

      “Dr. Fisch?”

       I look up from the progress note I am writing on a nineteen-month old girl with sepsis. Luckily, she is doing well, and is almost ready for discharge.

      “Yes, Terri?”

      The formality of the nurse’s address seems odd. I haven’t been called Dr. Fisch by staff since the first day I got here, when I was introduced to a nurse who asked my first name. “You don’t expect us to call you Dr. Fisch forever, do you?” And that was that.

      “Can you come examine this woman?  She’s pregnant, and complaining of bloody vaginal discharge. She was just here yesterday for the same thing.” Terri shakes her cropped blond head. Her voice is disapproving. Her purple stethoscope slips off her shoulder and she absentmindedly pushes it back up.

      “I’m not on call today.” I try to return to the chart in my hand, to finish the note I was writing.

      “Yes, Doctor, you are– for OB.” Terri persists. “Dr. Wilkes is on first call, but he doesn’t do OB, so you are his backup.”

      This is not uncommon. We have been extremely short staffed ever since I came to Barrow, AK two months ago. Because of this, we have locum tenens coverage whenever we can arrange it, and many of these temps do not do OB. But, when we have three full time docs instead of seven, (our fourth is on a one-month leave), we have to take what we can get.

        “Okay.” I resign myself to the interruption and put down the chart in my hand. I guess it is good I wore scrubs today.  “What is her story?”

      Terri struggles over the details. She is in Barrow as a travelling nurse, and is not trained in obstetrics. This is one of her first assignments since finishing nursing school. She takes a deep breath as she tries to organize her thoughts.

        “She’s a Prim-ip. It is her first baby,” she reiterates.  “Her E.D.C.,” she continues, enunciating carefully, “is in two weeks. She was seen and checked yesterday when she came in for the same complaint.” Her annoyed tone implies that this pregnant woman is wasting our valuable time.

      “And do you know what her exam was yesterday?”

      “Well, Dr. Gonzalez was busy in town, so he had Maria check her. She wasn’t in labor, although she did have some contractions on the monitor. The baby looked good. Her cervix was closed. ” This comes out in a rush. It sounds memorized.

      “Let me review her chart, and I will go chat with her.” Maria? She doesn’t do OB. Why would she do a cervical check?

      I quickly finish the note in the sick little girl’s chart, and go to get the OB record.

      I feel the familiar quiver of nervousness combined with excitement. I have come to Barrow right after residency, looking for a challenge.  Barrow is so remote that is it the number one site for reimbursement from the Indian Health Service, and quite an adventure.

      Medicine, as a whole, is different in the arctic. We have no specialists on site, and our radiology and laboratory capabilities are basic. We can only do plain films—we don’t have CT or MRI. Telemedicine is common in the Alaskan bush, but it has not yet come to Barrow. Many routine labs are send outs, which take several days to get back. And if the weather is bad, and the planes can’t get in, we can’t even get the blood out.

      Obstetrics in Barrow is the worst of all– it can be downright scary.  I did about eighty-five deliveries before I graduated from family practice residency. This is enough to feel fairly comfortable under normal circumstances, but obstetrics in Barrow is anything but normal. It is amazing, but I am more experienced in OB than any of the other doctors here, and I am the only one with any formal OB training. This is unnerving for me. Fresh from residency, I am used to having attendings looking over my shoulder. Sometimes, when I am nervous in the delivery room, I wish for the good old days when I had backup.

      It is not just that I am on my own during deliveries. There is no operating room, no anesthesiologists, and no OB backup. This means that there are no epidurals, and we have no c-section capabilities. None of the providers here are trained in C-sections anyway, so the lack of an OR is not a problem per se. None of the usual emergency interventions are available. We have a Lear jet. In an emergency, we can put a pregnant woman on a plane for the 770-mile trip to the Alaska Native Medical Center in Anchorage. The flight itself takes ninety minutes, and there is about half an hour on the ground on each side. The only other option is to pray. I find myself doing that a lot.

      We do try to limit the risk by weeding out any woman with any risk factor. Any serious medical problem, including, but not limited to, pregnancy-induced hypertension, gestational diabetes, multiple gestation, or history of previous C-section necessitates the patient spending the last four weeks of the pregnancy in Anchorage, waiting to deliver. This minimizes, but certainly does not eliminate, complications during deliveries.

      I quickly examine the chart, skimming the prenatal records. Margaret, the patient, is a twenty-two year old Native woman from Barrow. She has come to all of her routine prenatal visits, and her pregnancy has been uneventful. Her lab work has all been normal, including a triple screen. I notice this in particular, because I wonder how it happened that she had this test done. Most of the prenatal patients in Barrow do not have triple screens done during their pregnancies, nor do they have routine ultrasounds. We don’t have an ultrasound tech in Barrow, although about once a month a technologist is sent from Anchorage for a couple of days. These logistics prohibit routine ultrasounds, and the women are used to this.

      I go into the labor room. Margaret is the only labor patient we have on the floor. This is not unusual. There are only about eighty deliveries a year in Barrow, so we rarely have two deliveries going at the same time. Margaret looks pale and tired in her hospital gown. She still has her faded blue maternity jeans on, but the elastic “tummy” has been pulled down, to allow the monitor to be hooked up. Her shoulder length straight dark hair is pulled back in a bright blue barrette shaped like a star. I hear the reassuring “whoosh, whoosh” of the fetal heart tones. I estimate that the rate is about one hundred twenty, so I am happy. Margaret is calm, and doesn’t seem to be particularly uncomfortable. Her mother and several other Native women are with her.

      My nose twitches at the smell of snowmobile fuel. Margaret must have ridden one to the hospital. I smile at this as I introduce myself.

      “Hi. I’m Doctor Fisch.”

      “Yes, I saw you at the prenatal fair. You put that funny pregnancy belly on my boyfriend.”

      “The empathy belly? Yes, that was fun. He did look silly, didn’t he?”

      “He certainly did. I am still teasing him about it.”

      “So when did you start having contractions?”

      “Well, I started having some cramping yesterday. I was also having some bloody, mucousy stuff– you know, down there.”

      “And how is it today?”

      “About the same, maybe a little worse.”

      “Did they talk to you about bloody show yesterday? It’s very common right before you go into labor.”

      “Yes, they explained all that. But something doesn’t seem right, and my mother told me to come back and get checked again. I am glad you are here today- I feel funny with a man doctor.”

      “Okay. We’ll check you out. So far, the monitor strip looks good. The baby looks happy. Do you think it is a boy or a girl?”

      “I think probably a boy. If it is a boy, I am going to give him away– my auntie said she would take a boy, but she doesn’t want a girl, because she already has one.”

      “So what are you going to do if it is a girl?”

      “I don’t know. Maybe I will keep it, or someone in the family will take it.”

      These conversations had shocked me when I arrived in Barrow, but this sort of plan is so common that by now I am almost used to the idea. Almost.  I am still jolted a little every time I hear a woman say that she will only keep one sex or the other, or that she is going to adopt out the baby, but the adoptive parents only want one sex.  Adoption is very common in Barrow, and in the Alaskan bush in general. Because of this, when addressing any pregnant woman, I always check whether she plans to keep the baby before making any congratulatory comments.

      Margaret’s boyfriend has not come to the hospital, and this is not unusual. In fact, fathers rarely attend deliveries, even if they are currently involved with the mother and plan to keep the baby.

      It is time to do a cervical check, and verify whether Margaret is in labor. I leave the room to give her time to undress fully. I give her plenty of time—when it is really cold, the Natives often wear two or three pairs of jeans. Since I live in the hospital housing, and often don’t go outside for days at a time, I use the size of the pile of clothing as a rough guide to how cold it is.

      I return to the labor room, and help Margaret back to bed. Her mother and aunts hover as we make the necessary adjustments in the bed position, and I take out latex gloves and KY jelly. As I move the sheet, I notice that she has kept on her bright pink socks. Margaret and I continue making small talk as I start to check for cervical dilatation. She is chattering on, talking about baby names. Bertha tops the list for girl names. Old-fashioned names like Bertha, Mildred, and Martha are common in Barrow.

      “Wait. WAIT!” I suddenly feel a need to concentrate without the distraction of conversation.

      Margaret is stunned into silence. Her mother and aunts exchange looks over her bed.

      I can’t believe my fingers. Margaret’s mother was right. Something IS wrong. The cervix is dilated to six centimeters, and I can’t feel a presenting part. Then, something that feels like a little stick starts moving around and poking my fingers. I have never felt anything like that. What is that?

      Oh no. Oh no. I think I know what that is. I hope I am wrong. OH G-D I hope I am wrong.

      I try to remain calm, and not look as though I am terrified. This is a time to instill confidence, if at all possible. I certainly don’t want to scare the patient. I wish I felt confident.

      “Uh, Margaret? I’ll be right back.”

      “Doctor Fisch…”

      “Margaret–hang on. I just need to check something.”

      I scurry from the room, trying to think what to do next. Breech! The baby is breech! That was a foot that poked me! I am pretty sure, but I need to check. I need the ultrasound! Where is that machine?

      My mind continues to race as I head toward the clinic. I pitch forward and trip as I run down the hall to the x-ray department. One of the many people who came into the clinic must have dripped some ice off of his shoes, and the floor is slick. I catch myself before I fall, hike up my scrub pants, and continue toward the outpatient department. The hospital is all on one level, and the outpatient clinic is just down the hall from the inpatient ward. It takes just seconds to get there.

      “Ellen. Where is the ultrasound machine?” I breathlessly interrupt my friend, who is busy sorting x-ray reports. I nervously adjust my glasses.

      “It’s over there. But, uh, you don’t know how to use it. Remember?” She looks at me in disbelief.

      “I realize that. But I will figure it out. I think my patient is breech.”

      “Are you sure? Is she in labor?” Ellen realizes the implications of the situation, and knows now why I look so distressed.

      “I am not sure, but I am very afraid that she is breech. And she is dilated. Can you help me wheel this machine down the hall?” I am out of breath from rushing down the hall, and I try to catch my breath before I take off again.

      We bang the machine into each other in our haste to get it down to the labor ward. I look at the machine, turning it to the right and left. Ellen recognizes the problem, and quickly points out the on/off switch. I plug in the machine, and turn it on.

      “What? What’s going on?” Margaret’s eyes widen at the sight of the machine.

      “I just need to check something. Don’t worry. As soon as I am sure what is going on, I will tell you everything.”

      Even with my lack of ultrasound skills, I find the fetal head in the epigastrium. This is NOT a good situation.

      “Well, Margaret, it looks like the baby is breech. That means that instead of having his head down in the pelvis, he is backwards. His butt is down there instead of his head. Actually, his foot kicked me when I was examining you.”

      “Really? What does that mean?”

      I must be doing a great job of acting calm, because Margaret seems only mildly interested, and not at all concerned.

      “I need to talk to the obstetricians in Anchorage, and then I will discuss the plan with you.”

      I head out to the nurse’s station, trying not to run. I review things in my head. I need to stop her labor. How do I do that? Magnesium. Even though contractions are not registering on the monitor, she is obviously in labor, because she is six centimeters dilated. How much magnesium am I supposed to give? I need to call the pharmacist. I need to get hold of the OB on call in Anchorage. My thoughts are racing a mile a minute.

      “Terri?”

      “What do you need, Dr. Fisch?”

      “Can you call the Native Hospital in Anchorage, and find out who is on call for OB? I need to talk to whomever it is ASAP. And could you bring me Margaret’s chart again? Please?”

      Terri was in the room during the exam, and is aware of Margaret’s condition. She looks a little scared as she runs off to do what I have asked. I think she is afraid she is going to have to be involved with a breech delivery. Medicine in Barrow is as scary for the nurses as it is for the doctors. I would like to reassure her, but I right now I just don’t have the time.

        Margaret’s chart is lying on the counter, and I grab it and turn to the last few visits. Damn! Fetal position was NEVER documented in the chart, despite the fact that the flow sheet clearly has a space for position starting at 32 weeks. It is highly unlikely that the baby was vertex and has now turned. I bet the baby has been breech all along, but no one checked,  so no one noticed. Damn, damn, damn, damn, damn! How typical for Barrow.

      I run to my apartment to get my ALSO guide. It has only been a few months since I took the Advanced Life Support in Obstetrics course, and right now I am very thankful that I did. I can’t honestly say I remember anything about breech deliveries, except that you sometimes have to use backward forceps that have some name I can’t remember and that I can’t put together. I really, really hope I am not going to need any forceps today.

      As I run down the hall connecting the hospital to the hospital housing, I give thanks that the housing is attached, because otherwise it would take me several minutes just to put my clothes on to go out in the sub-zero arctic air. It takes about four minutes to get to my apartment, and I try not to hyperventilate on the way. I pass a group of hospital workers standing at the window, chattering and pointing. Despite my rush, I stop to see what is going on. A polar bear is standing outside on the ice, eating a seal. I take a quick look, and continue on toward my apartment.

      I barrel through the door, glad that there is no need to keep it locked. A six by twelve room serves as my pantry, and I go to the section that is full of medical books. I rifle through the textbooks and quickly find the loose-leaf folder I am looking for. I turn to the section on breech deliveries, and leave the apartment.

      Starting to review the information, I walk more slowly back toward the hospital. The folder is bulky, and awkward to read as I walk. Some loose pages fall out, and I have to stop, turn around, and bend over to pick them up before I can continue on my way.

      When I get back to the hospital, I call Julie Mack, who is acting clinical director, and tell her what is going on. Terri, the nurse, nervously approaches and tells me that she has Dr. O’Rourke on the phone. He is on call for OB at the Alaska Native Medical Center, and is waiting for my report. 

        “Hi, Dr. O’Rourke? This is Dr. Fisch.”

      “So the nurse tells me you have a primip who is breech? What is her exam?”

      “She’s about six centimeters, contractions q5-6. Baby looks good.”

      “Have you started the mag yet?”

      “It’s getting hung right now.”

      We continue reviewing the case. We agree that we will continue to monitor the patient, and see whether we can stop her labor with the magnesium drip. I am to check her again in an hour, and we will talk again then. The situation is too unstable to try to fly her out at this point.

      I realize that even though I probably can’t fly her out, I should call the medivac crew to check on the flying conditions. It doesn’t matter WHAT the medical situation is—the weather rules. Whiteouts are frequent, and “weather permitting” is more than just a saying. The medivac fleet includes the Lear jet, small and large helicopters, and twin engine planes. Having this variety of aircraft increases flexibility, but if the conditions aren’t right, we can’t fly. We have to improvise and wait for the weather to clear. Pilots in Alaska are some of the best in the world. They are used to flying in extreme conditions, but some situations are just too dangerous to attempt.

      

 

      I page the paramedic on call, and inform him of the situation. He will check on the weather conditions and get back to me.

      It is time to go check the monitor strips and update Margaret on the plan. The baby still looks good, and Margaret reports that there has been plenty of fetal movement. She is tolerating the magnesium drip without problems.

      I head back to the nurse’s station to review my ALSO manual. The information sounds only vaguely familiar, and I certainly don’t feel ready to do a breech delivery. I have never even seen a breech delivery. But this is typical for life in the arctic. You do all kinds of things you have never done or seen before. You look it up in a book, and try to do what it says. The old saying “see one, do one, teach one” is not applicable. Most of the time you don’t see any before you have to do one.

      It doesn’t seem like very long before it is time for another cervical check.

      “Margaret? Are you ready to be checked?”

      “I guess so. I haven’t felt any contractions in a while. Does that mean my labor has stopped?”

      “We’ll have to see. Excuse me, ma’am. Mom? Could you step over here?” I address the older Native woman sitting with Margaret as I try to get to the monitor to review the strips. By now the word is out that there is a problem, and a large group of family members have come to provide support. They are going in and out of the room, filling up the hall, taking turns keeping Margaret company. There are elders–aunts, grandmothers, and cousins with weathered faces, wearing their parkas with thick fur ruffs. Their only concession to the warmth in the room is to open the zipper at the neck. There are teenagers who are laughing and turning the occasion into a party. Many friends have also come. Several of the women have babies on their backs, with the tiny heads barely visible at the base of “mommy’s” hood.

       This gathering of friends and family is typical of medicine in the arctic. It is not unusual for several generations of a family and many neighbors to come and provide comfort when someone is ill. It can be overwhelming for health care providers, because many of the usual boundaries do not exist. Everyone is one big family, and issues of confidentiality are often blurry.

      Despite this, I shoo the visitors out of the room.

      “It is time to do a check. Let’s give Margaret some privacy.”

      Margaret’s mother stays to hold her daughter’s hand. She smiles reassuringly at her daughter.

      We adjust the bed again. The air is still, as we hold our breaths waiting to see if the magnesium has done its work.

      “Oh, dear.” I can’t help it. It just slips out.

      “What? What is it now?” Margaret looks at me questioningly.

      “You are eight centimeters. That is more than before. That means you are still in labor. I need to call Dr. O’Rourke.”

      I scurry from the room, trying not to show my anxiety. I quickly get in touch with Dr. O’Rourke. I share my dismay with him over the fact that the labor has progressed, despite the magnesium.

      I call in one of the OB nurses to double check my exam, and she corroborates my findings. In fact, she finds Margaret’s cervix has now dilated to nine centimeters.

      Dr O’Rourke and I reluctantly agree that there is no choice. We will have to prepare for a breech vaginal delivery in Barrow. The situation is too unstable to attempt to get to Anchorage. Although I don’t want to do a breech delivery, if it needs to be done, it should be done in Barrow, in a controlled setting. I certainly don’t want to risk doing my first breech delivery on an airplane.

      We move Margaret to the delivery room. I call Julie again to update her on the situation. She says she’ll be right down to talk to me.

      I sit at the desk and review my ALSO guide again. I attempt to visualize what a breech birth must look like. I try to gather my thoughts and remain calm despite the excitement swirling around. Margaret’s family is now milling around the halls and waiting room. Only her mother is with her in the delivery room.

      Julie hurries down the hall, carrying a book. She wants to meet the patient. I take her in and introduce her to Margaret. She explains, with her book open to the page on breech deliveries, that she will be doing the delivery, and that we will be using special forceps. I am watching in disbelief. What is she doing?!

      I suggest that I do the exam before she does, to see if it has changed at all since the previous cervical check. The cervix is definitely now at nine, but it is a tight nine, and doesn’t feel like it is about to change very quickly.

      As Julie and I walk out, we confer on what to do. She thinks I should write notes and monitor the labor, and she will come do the delivery when it is time. I am the youngest doctor on staff, and she expects that I will do what she tells me. I am not happy with this plan, and we briefly tussle. She explains that she figured I would want her to do it, as she is the acting clinical director, so she should take the responsibility. My opinion is that I should do the delivery, because I have more experience than she does. Although I am slightly tempted to dump the whole thing in her lap, I do already have a rapport with Margaret, and I believe I am better qualified to do the delivery. Julie and I eventually agree that I will do the delivery, and she will attend to take care of the baby. This is unusual, as one doctor usually treats both mother and baby. I agree that I will update her as things progress. She goes back down the hall to the outpatient clinic to see some of the patients who are piling up.

      The magnesium is off. I wait, pacing nervously, to do the delivery. I review the ALSO algorithm for breech deliveries over and over, and talk the procedure through with Dr. O’Rourke on the phone. He reminds me repeatedly that when the time comes, I need to be patient, and not pull on the baby. My palms sweat as I turn the pages for the eighth time. My glasses slip down my nose again, and I distractedly push them back up. I rarely wear glasses in Barrow, because they fog up when you come inside from the cold, and then you can’t see. I wore them today because I was running late, and didn’t have time to put in my contacts. I prefer to wear glasses when doing a delivery though, because they protect my eyes from bodily fluids, so I guess it is just as well.

       I have decided that I will check Margaret again after an hour. I glance at the clock. It is only two minutes since the last time I looked. I pace some more. I don’t hear any sounds from the labor room. I look at the clock again. Almost time. I will call the medivac crew and see what they found out, and then I will check her.

      The medivac paramedic says we could fly if we have to, but I would have to accompany them to Anchorage. The flight crew does not want to be in the position of doing a breech delivery. I reiterate that I don’t think we are going anywhere, but it is good to know what the options are.

      The moment of truth has arrived, and I go in to check on Margaret. I barely breathe as I glove up, and reposition the bed. Luckily, Margaret’s “bag of water” is still intact.

      As I find the cervix, I am nervous and excited. Although I am afraid, dealing with challenging situations is what medicine in Alaska is all about. I am as ready as I am going to be.

      I find Margaret’s cervix unchanged from an hour ago. I am relieved and disappointed. What should I do? I have to decide immediately. If we are going to go, there is no time to waste. Do I dare to try to get Margaret to Anchorage?

      I dare. I tell Margaret that things haven’t changed, and I am going to see if I can make arrangements to get her to Anchorage. I instruct the nurse to restart the magnesium, and walk quickly out of the room. I get Dr. O’Rourke on the phone, and after a quick consultation, he agrees to accept Margaret. I call the medivac crew, and tell them to come over to the hospital ASAP. I also call the OB on call in Fairbanks, which is 40 minutes closer than Anchorage, and apprise her of the situation, just in case we need to divert the plane.

      All that done, I go to talk to Margaret. I explain that the plan has changed, and I think it is safe to transfer her to Anchorage. I try to sound confident that we will be able to get to Anchorage for the delivery, but there is no real way to tell. We quickly restart the magnesium drip, and start the preparations for transfer. Margaret’s mother goes out to inform the visitors of the change in plan.

      Things go quickly from here. We fill out all the necessary paperwork. We finish as the medivac crew arrives, and they move Margaret to the gurney, and wrap her in a bright orange papoose to ready her to go. I head down to my apartment to get ready to go.

      Word of the medivac has spread, and as I walk back to the hospital carrying my winter gear, several friends come up to me with shopping lists. Food and other supplies are very expensive in Barrow, (avocados cost six dollars a piece), because everything is flown in by plane. To offset some of the expense, everyone shops in bulk in Anchorage whenever possible. After dropping off a medivac patient in Anchorage, the flight crew usually heads to Costco for shopping. Another stop is at a fast food place to buy food to bring back. This is always popular, because there is no fast food in Barrow. I like to bring back Taco Bell, because it reheats well. I take all the slips with my friend’s grocery orders, and shove them in my pockets, as I hurry back to the ward. In the ambulance bay, I awkwardly put on my coveralls and parka while the crew loads Margaret into the back of the ambulance.

      Margaret is calmer than anyone else on the transfer. She has no idea of the dire possibilities, and we all prefer it that way. With a minimum of fuss, we get to the airport, and load Margaret into the Lear jet. The plane is small enough that I always joke that it needs a sign advising, “If your butt is bigger than this box, you can’t fly on this plane.” As I look at it as a potential delivery room, my pulse rises.

      We take off smoothly after strapping Margaret in and hooking up all the monitors. The plane is loaded with an isolette, which I hope we won’t need. Margaret remains relaxed and cheerful as we head toward Anchorage. She seems to regard the trip as a great adventure, Travel from Barrow is very expensive, so after she delivers, she will undoubtedly take advantage of the free trip by visiting family, shopping, and seeing movies. There is no movie theater in Barrow, few restaurants, and stores mostly with essential items. This trip to Anchorage is an unexpected bonus for her. When she flies back to Barrow, the hospital will make the arrangements, and the Native Corporation will cover the cost.

      The flight proceeds without incident. The fetal monitor continues to show a reassuring rhythm. Occasionally Margaret grimaces in pain, and I have a reflex rise in my blood pressure. I really do not want to do a breech delivery when we are this close to getting to the obstetricians. I am in over my head, and I know it.

      I made the decision to transfer, and no one has questioned it. I believe it was the right decision, but it was made based more on “gestalt” than on any medical algorithm. If there are complications, this is a decision that might be difficult to justify.  The legal ramifications are a consideration, but more importantly, I don’t want anything to happen to this woman and her baby. 

      Every time Margaret winces, I wonder if there is anything I can do. Should I adjust the magnesium?  The oxygen?  Try to turn her more onto her side? She is already lying flat, to prevent pressure on the cervix. I feel I should do something, but there is really not much to do except get to Anchorage and the OR as fast as we can. I shift nervously in my seat, tapping my wet boot on the rubber floor.

      Despite my anxiety, we arrive in Anchorage without complications. The trip to Alaska Native Medical Center is completed with expediency. We transfer Margaret, quickly giving report to the accepting medical team. The nurse settles Margaret in to her bed and hooks up the fetal monitors, getting ready to examine her. I breathe a huge sigh of relief that I am no longer responsible for her care, and turn to leave the room.

      As I approach the door, and turn the knob, I hear Margaret’s urgent yell. I look over my shoulder.

      “I HAVE TO PUSH!”

      I grin to myself as I continue walking through the door.

      A healthy six pound twelve ounce boy named Gordon is delivered by c-section forty minutes later.