“The women aren’t here for us.”

Standard

I was in a meeting after some horror show had played out in the birthing unit. It featured a ruptured uterus, a dead baby and multiple units of blood, and the STAFF were traumatized. We were planning a debriefing session: the venue, the time, the invitee list. One of the managers thought we were taking things a little too far. She said, “We have to remember, the women aren’t here for us”.

Are the women here for us? Not exactly. But care is not a one way street, and we need to talk about that.

I listened to Dan Ariely’s TED talk “Our buggy moral code.” Dan spent months; stretching into years, in the hospital after third degree burns affected most of his body. During that time he had to have many painful wound dressing changes. You may have heard that having burn wounds attended to is one of the most painful things imaginable. Dan said that the nurses would rip off the dressings quickly. And, they would start cleaning the most painful parts and work their way towards the least painful. They would rush through the work as quickly as possible. He would beg them to do it slower, give him a rest, save the worst parts for last, but they said “No, its better this way. It would be much more traumatic, if we did it the way you suggest”.

Once Dan got well he started doing research into whether what people believed about pain was true. He did a number of experiments using small electric shocks, plunging ice baths, vice grips on fingers, things like that. He rigorously measured the responses to the degree of pain his subjects experienced. Dan found that the average overall pain that people experienced was much reduced if things were taken slowly. His work revealed that many of the things that health care workers did to burn patients as a matter of their intuition were wrong and should be changed.

There are two powerful messages in Dan’s story. The first is the message that the patient is often right. We should listen to our patients much more than we do.

But I’d like to deal with the second message, made very clear went Dan went back to the hospital and spoke to the staff who looked after him. He explained his results to his favourite nurse. She said that there was one very important thing that Dan didn’t measure. He hadn’t looked at how the treatment made the nurses feel:

She said, “Of course, you know, it was very painful for you. But think about me as a nurse, taking, removing the bandages of somebody I liked, and had to do it repeatedly over a long period of time. Creating so much torture was not something that was good for me, too.”

In obstetrics we are the creators of torture. We often are witness to suffering, many times we, like the nurses who looked after Dan, are the ones inflicting it. We are regular bystanders, harbingers, creators of pain: we are victims of vicarious traumatisation and perpetrators of violent acts. It is true that sometimes we save lives in the process. But these uglier views of typical clinical events must be faced and examined carefully.

It is not good for staff to come to work and harm patients in the course of their care: intentionally or unintentionally. But the nurses did hurt Dan, they felt they had to, as part of their job. The pain they inflicted affected them so deeply they could not listen to what Dan was saying. Some part of their selves disengaged.

The day of the horror show, a mother was hurt and a baby died. I’m not getting into the fault of it. The thing is we were the audience and the cast of a tragedy. We need to review that play and not only to find out what scenes might have been better acted.

I think that when the manager said “the women aren’t here for us” she was extorting us to remember our non-starring role: the women aren’t here for our entertainment. She felt we should keep this professional distance, keep our emotions in check, toughen up and get back to work. The implication was there that if we didn’t, there was something wrong with us. But there is something more wrong when we don’t take the time to consider not only what happened, but how we feel about what happened.

There are times, I get called in to look at a tracing, or to give some advice, to births I have no other business being at, and when I get there, I realize that my services are not required. The woman is being supported, the midwife and family are there, and whatever they called me to do was a false alarm. Still, it is very hard to leave. I mean, it’s easy to leave a place where you are not wanted….but in this case, there’s a feeling of going out into the cold rain from a warm hearth, and you would like to linger, you would like to be invited to stay. But I don’t. That women wasn’t there for me. It’s enough for me to know that the warm hearth exists.

Instead, I’ve got a permanent invite to the parties that no one wants to attend. There’s a rush of adrenaline with all the drama of a five alarm fire. There’s a ruptured uterus, a dead baby and multiple units of blood. Like they say, it’s a crazy job but someone’s got to do it. Turns out that women want that someone to be a person who cares deeply about them.

Why Do Bad Maternity Systems happen to Good People?

Standard

The truth is that just because there is a better way doesn’t mean that’s the way it’s done.  I had an “aha” moment about why crappy care prevails in health care—-in particular, why women are still being abused and traumatized when they come to hospital to give birth— when I listened to this podcast  on the “religious” CBC radio programme Tapestry.  In the podcast, Mary Hynes interviews Gretta Vosper, an ordained minister of the United Church of Canada. Gretta tells the story of a particularly bitter conflict which had emerged within her church community and the pain that conflict had caused her.  She questioned why it is that in so many church settings, the meanest voices seem to own the podium.  What is peculiar to our humanity that this happens so often?

The reason, Gretta said,  why the bullies often win is that they exploit a loophole in our human nature.  Most of us want to get along and not be confrontational, so even in a place like a church where you would think people are mandated—commanded even— to get along and have empathy with each other, the bullies are set up to win.  Even in a place like church.  One bad apple can and does spoil the whole bunch.   A cursory look elsewhere in human history confirms this.  Why don’t we speak up? Why don’t we call evil out wherever it happens?

If churches can at times be hotbeds of hatred, is it really a surprise that health care workplaces are so often such unhealthy places for both the sick and the people who care for them?  Is it really so strange that hospitals are the institution where vulnerable people go to be healed but all too often come out further wounded?  That working in health care feels like being cast into both roles of an abusive relationship?  We are perpetrators, and sometimes victims.  We should perhaps be more often surprised under the circumstances when we get things right.

Since health care workers are the workforce of hospitals as well as being  members of the caring profession you would be forgiven for assuming that hospitals should automatically be workplaces filled with kindness and empathy. Indeed, kind people are attracted to the health care field but kind behaviours are often suppressed.  Horizontal and vertical violence are rife.  There is a combustible mix of people with the “disease to please” and one or two power brokers ready to exploit that: taking advantage of the softer nature of others as increasingly a certain management model and style has set in.  Staff are overworked and underpaid as managers are rewarded and in some cases paid bonuses for balancing the budget on their backs.  We are told that the patient comes first, and we have to do more with less, we understand that—-and people are being stretched beyond their capacity.  If we don’t look after our staff at a very basic level, they can’t look after anyone.

Once, I was finishing a caesarean section late at night.  My house officer assistant and I were both very tired. When we went to apply steristrips before putting the final dressing on the wound, we were clumsy with fatigue, accidently pulling off the steristrips we were trying to put on, making them stick to each other, having to redo some, and dropping swabs and equipment on the floor.  We were moving in slow motion, and screwing up out of sheer exhaustion.  The scrub nurse was watching us, and suddenly, she got so frustrated and angry that she lost it. She snarled at us to get out of her way, slammed on the dressing, and proceeded to very roughly take down the sterile drapes.

When that nurse ripped off those drapes, the drain I had put in the woman’s abdomen pulled out partway and I had to take down the whole dressing in the recovery room and remove it. It wasn’t a big deal, but maybe it could have been.  There might have been some sort of consequence for the woman, the newly minted mother at the end of the drain.   Infection, a missed haemorrhage. Certainly it was unkind.  And it is a million little unkindnessnesses that stack up together and make us all victims of the bad maternity system: the patient, the nurse and me.  I was too exhausted and too afraid to tell this nurse that her bitchy behaviour had caused a problem for the patient, because, in one part, the confrontation was just going take too much energy for me to muster up.  The next time I’d see that nurse she might make trouble for me.  In another part it was also because this small seemingly insignificant example of crappy care is a lot more common than you’d think.

Maternity care in too many parts of the world is an assembly line of impersonal care, provided by wounded healers working in a broken system.  We must do something different than we are doing now.

PS. I wrote this after reading this excellent post of Sheena Byrom’s here (where you can also download her awesome presentation about maternity care in the UK).  In it she asks why we aren’t following the evidence and changing the maternity system for the better.  And it got me thinking.