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And what about the baby? About Virginia Apgar who cut infant mortality in the United States in half

"Today we look at every baby born in a hospital through the glasses of Virginia Apgar" said one of her students

Virginia Apgar in 1966. From Wikipedia
Virginia Apgar in 1966. From Wikipedia

Joel Fleischman was born somewhere in the sixties of the 20th century and was always considered a child prodigy destined for greatness. In keeping with his ambitions, Joel, the typical New York Jew, wanted to be a doctor.

Upon leaving college, he received a scholarship from the state of Alaska that financed his studies for four years in medical school.

Joel considered himself lucky, but forgot to read the fine print on his scholarship. Instead of finishing medical school and going directly to some prestigious residency at Mount Sinai Hospital, he was forced, according to the terms of the scholarship, to serve as a family doctor in the God-given town of Sicily, Alaska.

This, in short, is the frame story of the television series "Exposure to the North". The thing I wanted to take away from the series is the following question:

Is everyone who, like Fleischman, did not have the money to finance his medical studies doomed to professional dissatisfaction? Does the fact that you didn't get a reputable internship, in a prestigious hospital and you didn't receive guidance from the best experts condemn you to be a small doctor? One whose contribution to the community may be great but his contribution to medicine is non-existent? Does the fact that you are stuck in a position that is closer to that of a nurse than that of a doctor necessarily mean that you have nowhere to develop?

Virginia Apgar was born in 1909 in New Jersey. Even as a girl in high school she knew she would be a doctor. She graduated with honors from her zoology studies at Holyoke College and began studying at the Columbia University School of Medicine in 1929, a few months before the outbreak of the great economic crisis in the United States. Unlike Fleishman, Virginia Apgar did not receive any scholarship. She paid her school fees through a loan and lived as a destitute poor woman. Nevertheless, she completed her medical studies with honors and began a surgical residency - the pinnacle of ambition for every doctor at that time, both in terms of status and salary. Maybe, just maybe, if she gets a job as a surgeon she can pay back her student loan in less than ten years!.

It is not clear in which parallel universe Virginia lives, but ours brought her back to earth very quickly. When she finished her internship, eight years after she started studying medicine, the economic crisis was in full swing. The market was saturated with surgeons. Even experienced surgeons had difficulty finding high-paying work. And she, not only was inexperienced, she was also a woman. Alan Whipple, the head of the school, gently explained to Virginia that she might be brilliant, but there wasn't a single woman who studied surgery under him who actually worked as a surgeon. He suggested that she switch to something a little more feminine, maybe practice anesthesia. This field needs someone with energy and intelligence to advance the field, someone just like her.

On the one hand, what Alan Whipple suggested to Virginia Apgar was insulting. Just as you would offer an outstanding graduate of the Department of Economics at Harvard University to work as a teller in a bank. Anesthesia was not really considered a branch of medicine. It was something nurses do. There was very little research in the field, no organized and agreed upon training program for anesthesiologists and very few people to learn from. The salary of those who dealt with anesthesia was accordingly. Their salary was less than a tenth of the salary of a surgeon, less than a third of the salary of professional doctors and less than half of the salary of radiologists. No one wanted to be an anesthesiologist - it was an admission of failure. Just like being a family doctor in Alaska.

On the other hand, Alan Whipple pointed out to Virginia Apger the urgent need to push this field forward both in terms of research and in terms of training doctors and setting standards. As a surgeon, he knew how important it was to have someone who could keep the patient on the one hand unconscious during the operation and on the other hand alive. The surgeons did not have enough knowledge on the subject but as of that time most of the anesthesia was performed by nurses who followed the instructions of the surgeon who most of the time did not know what he was doing.

Virginia chose not to be offended. She probably also came down to earth and realized that somehow she just had to pay back the loans she took out for the purpose of studying and this was not the time to be picky. $4000 of debt in the middle of the worst financial crisis ever is no laughing matter. She will try conditions and started looking for someone to teach her to become an anesthesiologist. It was not a simple task, as mentioned, there were no organized training programs on the subject. Luckily for Virginia, she was accepted to an anesthesia residency with Ralph Waters at the University of Wisconsin. A pioneer in the field of anesthesia, a serious researcher and a man with a vision.

Virginia actually studied in the first cycle of Waters' training program for anesthesiologists. Did someone say something about anesthesia being a female field? Apgar was the only woman in her entire cycle. Medicine in general was not a female field.

Everything is fine and dandy. Virginia Apgar returns to Columbia University and builds, together with Alan Whipple, a multi-year plan to establish an anesthesiology department at the teaching hospital, recruit physicians, an intern program and a research department. On paper everything looks great.

I still haven't found the parallel universe Apgar lived in, but it may be the same parallel universe Alan Whipple lives in. In the first year of the establishment of the anesthesia department, not a single doctor came to practice. Virginia was the only anesthetist in a hospital that performed more than 5000 operations a year. Even when several interns arrived, the surgeons treated them like nurses. They tried to give the anesthesiologists instructions on how to anesthetize the patient, even though it was clear that the anesthetists' knowledge of anesthesia was immeasurably greater than that of the surgeon. The salary remained on the floor, the research was simply not carried out because there was no time and money. teaching? Who has time for teaching? and place? All this simply failed to deter Apgar. She began teaching her interns in hospital corridors, in patient rooms, while working and whenever possible. She always walked around with a skeleton for demonstration and when there wasn't one, she demonstrated on herself. She wasn't shy about talking about body parts or letting students touch her tailbone, there's no shame in vision. Somehow it is hard to imagine a professor in a tie in the XNUMXs teaching like this. In Virginia Apgar's parallel universe, the worse the conditions, the greater the success. Despite all the difficulties, she became known as an excellent teacher and also managed to write the first ever textbook on anesthesia. The number of permanent interns and doctors increased slowly and after a few years it was time to open a real anesthesia department and such a department needed a real manager with a real salary. As I remember, the workload and teaching and lack of budgets did not allow Virginia to engage in research. The head of the anesthesia department needs a research background, right? Not to mention that managing a serious department like the anesthesia department cannot be given to a woman.

Again, Virginia was not offended. She simply returned to medical school at Columbia University and began doing research. The first woman to receive a degree from the Columbia University School of Medicine. Virginia's research topic had to do with babies. One intern in the maternity department asked her how to quickly assess the condition of the newborn. This was an unusual question, because the assumption until then was that the one who needed medical attention was the woman giving birth. The newborn is considered healthy except in very exceptional cases. If he cried even a little, it was a sign of good health. More surprising is that no one took this question seriously in light of the fact that in the US, the infant mortality rate in the first 24 hours after birth was one of the highest in the West at that time.

One of the responsibilities of anesthesiologists was resuscitation. The obvious signs that an anesthetized patient needed resuscitation were simple. Virginia simply took a napkin and gave the intern the same signs she would check on an anesthetized patient. Heart rate, breathing, muscle tone, reflexes and skin color. In order to decide if resuscitation is needed - a score between zero and two is given to each of these parameters and added up. If it comes out less than 3 - immediate resuscitation, if it comes out above 7 everything is fine. Those of you who read this card that was written when one of your children was born, saw somewhere between weight and body temperature this sum called the Apgar score.

At this moment began one of the most classic studies in the history of modern science. Virginia Apgar was not content with scribbling some test on a napkin, she decided to devote her research to reducing infant mortality. She started by making sure her test was indeed good. Statistics collected on tens of thousands of babies proved a direct link between a low Apgar score at birth and a high chance of death in the first 24 hours. Moreover, there is a direct connection between a low Apgar score and some kind of breathing problem - and therefore an urgent need for resuscitation. Well, so the test does do its job. Now we ask, what causes so many babies to have a low Apgar score? Apgar's initial assumption was that the anesthetics used in maternity rooms somehow passed to the newborn and caused him to lack oxygen in his blood. Here was a surprise. The statistical analysis did not reveal a direct relationship between a low Apgar score and a low oxygen level. Hmmm, what are we doing?

Let me introduce you to your best friend pH.

pH is a measure of the level of acidity in substances or solutions that ranges more or less between zero and 14. pH 7 means balanced acidity. pH 14 means that the substance is a strong base - for example caustic soda - unsympathetic. pH 0 means the substance is very acidic. Our saliva, for example, is pH 6 - more acidic than water. Coffee 5, cola or tomato in zone 2 - that is, very acidic.

The pH level in human blood is about 7.4, which means it is more basic. A pH level of 6.8 means you're pretty much dead. If you want to experience what a tiny change in the pH level of your blood does - try running a few hundred meters in a freestyle run. The activity of the heart, the accelerated breathing and the breakdown of carbohydrates as a result of the activity produce a lot of acid - which pulls the pH down a little. The muscles are fossilized, the air runs out, the feeling is horrible. You pant like dogs long after the end of the effort - the body tries to get rid of the excess acid in the blood. The pH must return to a higher level.

After seeing that the oxygen level in the blood is not the problem of the babies, Virginia Apgar went to check the pH level and what she found there...

"The pH level in the blood of these babies was so low that no one believed that these babies were alive. They were born with metabolic and respiratory acidosis, before it was common to think that it was impossible to have both. Well, you can, when you suffocate, and these babies were born in a state of suffocation."

But what suffocates the newborns? At that time, the usual anesthetic for childbirth was cyclopropane. The main problem with cyclopropane was its explosiveness and the careful handling it required. Now there was another reason why to stop using it. Apgar discovered residues of the anesthetics given to the mothers in the blood of the newborns. With the help of some colleagues from the cardiology department, she discovered that cyclopropane simply makes babies stop breathing. Doctors who gave mothers cyclopropane during childbirth, whether by caesarean section or normal delivery, actually suffocated the children!

More than twenty years since she began her career as an anesthetist, Apgar received the recognition and respect she deserved, but if you expected a woman who suffered all her life from discrimination on the basis of sex to join the American women's liberation movement, which took its first steps in those days - you are wrong. Perhaps because of the fact that she was successful despite the discrimination, or because she thought that claims of deprivation were just an excuse for inaction, she cut herself off from the struggle of the feminist movement. Another possible reason was the direction in which the struggle went. The main point of the struggle in those days was subsidizing day care centers for children to allow mothers to develop a career on the one hand and not to give up starting a family on the other. Unlike these mothers, Virginia Apgar never married - according to her, she could not find any man who knew how to cook. She also had no children. Maybe she just didn't identify with the struggle that was the essence of mothers.

Virginia Apgar died in 1974 when she was appreciated by the entire world of medicine in general and the field of anesthesia in particular.

In 1995, the United States Postal Service issued a stamp bearing Apgar's portrait. A student of hers pointed out at the ceremony that today we look at every baby born in a hospital through the glasses of Virginia Apgar. How is that an achievement for you Joel Fleischman?

11 תגובות

  1. To Michael:
    You wrote that "even today there are few doctors who want to specialize in anesthesia and the main reason for this is the weight of the responsibility".
    What do you rely on? Is it just a personal opinion?

    As far as I understand, liability is actually the only reason why doctors sometimes want to specialize in anesthesia (besides "default").
    Doctors start medical school precisely with the ambition to save lives, and anesthesia actually makes this possible.
    The problem is that the disadvantages are greater than this: boredom (a little activity at the beginning of an operation, a little activity at the end, and if nothing happens, then it sometimes turns out to be actually hours and hours of staring at screens with animal indicators, and occasionally small additions to the infusion, and back to the screen), lack of Adequate financial compensation (insignificant to invisible salary increases, in most places), lack of adequate human compensation (the surgeon gets all the fame and thanks of the family), long and multiple shifts (due to the distribution of the heavy burden on the minority of patients), and I must have forgotten more.

    It seems that too little has changed since Apgar's days...

  2. The picture of Rafi Arzi that appears here above, also appears in the link you gave. From this it can be concluded that it is the same Rafi Arzi.

  3. What a beautiful article and what a great woman!
    By the way, to the best of my knowledge, even today there are few doctors who want to specialize in anesthesia and the main reason for this is the weight of the responsibility.
    Is the author of the podcast the same Rafi Arzi mentioned here?
    https://www.hayadan.org.il/famlab-2011-2005116/

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