The obstetrician’s dark gallery

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The writer Anne Lamott tells her writing students that they should always write out of vengeance, as long as they are nice about it. I mainly write out of a longing to make sense out of things, but maybe there is room for improvement.  According to Anne, there is a trick to doing this vengeance writing thing without getting sued.   You can go ahead and write about the boss you hate, the ex-husband you despise, in fact, you really should write about them, says Anne, but if you have a boss or an ex-husband who has an identifiable set of unfortunate personal characteristics she says you should probably change these details dramatically.   So, she tells us, if they are known for their long toenails, give them tufts of nasal hair instead. I think that filling their ears with tufts of hair too, would be a nice touch, as a good crop of ear hair can explain perfectly why they don’t hear anything but the sound of their own voices.  It is a good idea to alter a few things in their personal lives, marry them off to unfaithful spouses if they are single, and divorce them several times over if they are married.  Leave out the plastic surgery they had, and the membership in the hair club for men (So unfair, how hair follicles are assigned!)  And —I saved her best advice for last— give them a small penis.  They will never sue you when they recognize themselves in your writing, if you make a few alterations to their physical self and life, and give them a teenie little penis.

It’s not like I’m not tempted to write about any number of previous or current bosses, but what I’d really like to write about are my patients, and the midwives I work with, and my  friends and colleagues, and there’s a problem with that.   I can’t give them small, or even large penises.  In the first place, the big dramas, the things I’d most like to tell you about, the things that fill my diaries and get up in the middle of the night and stomp around in white bloodstained gumboots, those things happen to the penis-less among us. This is not a coincidence.  To disguise the details is also problematic.   It is in the exact details that the horrors are fully revealed.

Agatha Christie once said that it is a curious thing what one remembers.   You never know what is going to be permanent.   If my head were made of paper mache, the births I’ve attended would be posted like bills in a gallery of their own inside it.  There are many of them so it’s crowded, and they get papered over under layers of other births.   I remember the ones that soak and bleed through like wounds that cannot be staunched, no amount of plastering and bandages are enough.

I have presided over some deaths, and there they are, scenes of tragedies, in the obituary section.  A recent addition is a couple who came in last week.   I see them clearly, their heads bent together making a little drawbridge over their grief.   My colleague and I are taking turns operating the ultrasound.   It takes seconds to find a beating fetal heart with a scanner in a full term baby.   It takes a couple seconds more to break a mother’s heart when you can’t find it.   A few extra seconds of scanning: a lifetime of grief.

Over here, in the same week’s catch, another baby-shaped void, but she’s not dead, only missing.  This one’s been uplifted, there’s a misnomer, it’s the word they use when babies are taken off their mothers.  Mothers who are bad, or mad, or addicted to drugs, or in this case, all three.  This mother’s eyes look back at me like two deep wells when she asks me where her baby is when I visit on rounds the next day.  In those wells there is a sadness that surpasses understanding, a deep tissue sadness that no drug can penetrate.

In my brain there is a dark lit gallery where these portraits hang, portraits of mothers who lose their babies, lose their minds, and have had their minds fucked over, purposely.  “Don’t you want what is best?”

It is depressing, and I don’t mean for you to feel that way.  When one becomes depressed, it is because one realizes that life has no purpose. Patients sometimes say an obstetrician’s job must be so fun.  We know our speciality is often full of sadness. Patients know this too, if they think about it for a moment. The psychologist Jordan Peterson said “Everyone knows that life is tragic.  Everyone knows that to exist is to suffer.  And one logical and appropriate response to this is to be grateful in spite of your suffering and attempt to make the best of it.”   I am not going to do this.  I will not be grateful in the patriarchy.  But here I must tell you the all-purpose cure for depression:  the one and only cure that doesn’t involve denial or repression.   It is this:  to try if we can to alleviate the suffering in others.  And when we cannot, it is to bear witness, to be in solidarity, to say, yes, it happened to me too.   I add to my gallery every day.

The most beautiful section in my gallery is the exhibition of the births of my own children. They are on the innermost layer of paper mache, but visible at all times to my inner eye.  Like all mothers, it doesn’t matter how long ago it was.  The images don’t fade.  My oldest son’s birth was painted there by Michelangelo.   There, in the Sistine Chapel of my brain, he is dancing out of my body.    He spins upwards like a baby dolphin, dark wet, and slippery, breaching the surface of the universe.   He is half an infant god, and I am the goddess mother to whom he needed to return.   My arms fling outward to receive him.  And his arms fling upward to reach mine.   Our fingertips almost meet.     It is an exact copy of Michelangelo’s painting in the Sistine Chapel, where God’s fingertip reaches out towards Adam.   Divine sparks are flying from our outstretched beseeching palms.

This must be a multimedia exhibit, because I hear myself saying to the doctor, “Please, can you give him to me right away?”    But at that precise moment, the sacred moment of my son’s birth, an anaesthetist walked into the room.  In that moment of dithering my doctor stops, she hesitates, she is confused for a moment, and then she gives my baby to this higher power instead of giving him to me.   I had no need of anaesthetic.  My son had no need of neonatal care.   But later I find out that in the Canadian medical system, if that anaesthetist gets your baby he can do something you, the mother, cannot do.  He can bill the government for resuscitation.

Where exactly do these men, those anaesthetists, the alpha males in charge, that swagger with their male privilege into our spaces, those of the small and large penises and untrimmed toenails and unhearing hair-filled ears, where do they think they started out?  Do they not know they hang in a gallery in some other woman’s brain?  Were they not little boys at one time in their lives?  When did they become such assholes?  Isabel Allende says that misogyny trickles down.  There is always some woman to be abused.  But where is the wellspring?   Let’s shut it down.

St Augustine, before he became a saint, wrote a manual called the City of God, in which he touched on the woman problem. The latest Pope has solved the dogs-going-to-heaven issue, back then Augustine grappled with the question of the female immortal soul.  Men, self-evidently, were created superior from the get-go.   In my view you could count them as the first draft.  The shitty first draft, Anne Lamott might say.   Not so the wise men of that era.   Augustine wrote that, by virtue of women’s inferior shitty second-class draft status, no matter what godly deeds they did in their life on earth, they could never be the equal, let alone superior, to any living man.  Fortunately, there was hope in the afterlife.  Once women were actually admitted past the pearly gates, like cripples and the blind, we’d be restored to a perfect state.  In the case of women, it means that we will get a penis.  If we are good and virtuous in this misogynistic life, it is meant to be no small measure of comfort that we will get a penis of our very own.

*********************************

I am on call, and a woman comes in bleeding, 30ish weeks pregnant.  She is haemorrhaging badly.  We rush her to the operating room.   Her partner, the one with the swastika tattoo, is anxious and pacing.  There is a letter in the notes about domestic violence and the police.   His last baby was born by c-section, (to a different partner, he’s on his fifth or sixth now), he’s an expert, he mansplains what I’m going to do.   But those babies weren’t premature and this is different.  He is not cutting the cord, there will be no skin to skin.  It’s not on purpose, we want these fathers, all fathers, to attach, to bond.  So they don’t kill their babies or their partners for starters.   The woman is unstable, and the anaesthetist needs to give her a general anaesthetic, and this means he’s not allowed into the operating room. When he’s told the plan, he loses it.  The aggression and verbal abuse escalates.  We have no time to cross match blood, no time to deal with years of trauma, no time to dismantle systemic racism and misogyny.  I try reason:  it doesn’t work.  That chills me, because it almost always does.  I’m nice.  Really nice.  It scares me when scary people don’t respond to reason and to genuine kindness.

 “How dare you goddam bitches keep me away from the birth of my child?”   He raises his voice, his face is too close to mine, he knows what this is about, “You fucking cunt.  I know my rights.  You are discriminating against me!    All because I have a dick”.

“No”, I hear one of the staff say, moving her body like a shield between us. “It is not because you have a dick, it is because you are acting like one”.

I flee to the scrub room.  In a few minutes, I find myself in a company of women, surrounding this mother, our heads bowed, a scalpel in my hand.

 

On the penalties you pay for believing in women

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On the first day of my first obstetrics rotation as a medical student, I got to attend a birth.  I was assigned to shadow one of the staff obstetricians. We waltzed in unannounced to the room of a labouring woman, who was pushing, feebly, ineffectively, with her feet in stirrups, legs encased in drapes.  The doctor turned to me and rolling his eyes said, “At this rate, we could be here all day.  Nurse, get me a pair of forceps.” And then, for what seemed to be no reason at all, other than impatience, he pulled the baby out.    It was awful and I remember feeling terrible for everyone….the mother and her baby, the nurse who had to “obey” and for myself for having to bear witness to this thing. 

 What did I do with those feelings?  Did I report this behaviour to the proper authorities?  No, I certainly did not.  It was clear to me that this was how it was going to be, that shocking things like this were – shockingly – forbidden to be viewed as shocking at all.  The way everyone else around me was acting it seemed to be the expected norm.  The staff doctor was my boss, and he was at least in part responsible for my grade during that rotation.  I was in no position to complain.   

To be fair to the obstetrician, as a student, I didn’t understand everything that was going on.  It could have been that there was some other reason to deliver the baby that way that I didn’t fully appreciate.  Maybe the fetal heart rate tracing wasn’t optimal.  Still.  I’ve had many other experiences of the same kind in my training and beyond, enough to know that this kind of casual approach to violent events is commonplace.

By looking at me and speaking to me in that way, including me as a sort of a peer… “we could be here all day” ….. I was being asked to take sides.  It was as if I was being groomed for something.   Grooming can be quite flattering.  You don’t want to speak out because you are afraid of being humiliated.  This doesn’t change the fact that you are complying with the abuse of women. But you are complicit in an act of oppression for the same reasons everyone complies with oppression, because you are weighing the risks and the benefits of non-compliance.   You are performing complex calculations in your head, below the level of your cerebral cortex.  Who would have known the brainstem can do this kind of math? 

It’s a survival mechanism though.   We need to suppress this information from our conscious selves to function in this system.   We are helped to suppress our empathy in so many ways.  In the hospital setting we make the patient seem “other” than ourselves.  The patient gets a hospital gown and an arm bracelet to segregate and anonymize her. The patient I described in that story above didn’t even have a name.

We do these things in part because at times we have to do horrible things to people in the name of helping them….for example, most days I’m cutting into the flesh of women which could—perhaps even should– be repulsive and frightening but I have learned not to think about it in that way. It is easier to think you are cutting into a piece of some sort of material and not, you know, an actual woman.   

The problems happen sometimes when the patient seems too much like us.   As long as the patient comes from some sort of difference:  age or race or socioeconomic class, it’s okay*, but then, someone comes along and bam—-all of a sudden we have trouble.  For example, I once had a lot of problems staying out of grief with a dying woman who –though not related to me—happened to have the same last name, and children around the same age as mine.  (For the record, staying connected to her as she died was a transformative event in my medical life, which is to say, my actual life.)

And then there are the very scary things that happen.   Like when patients bleed to death and babies die.   After half a dozen or so of these sentinel events as they are called, we start maybe exhibiting some of the signs of post traumatic stress disorder.  We shut off even more.  We abuse patients, for better or worse, we are perpetrators.  We become that obstetrician that I followed on the first day of my obstetric rotation.

Not much is written about the perpetrators of violent crimes. They aren’t usually the ones seeking therapy.   I read a book recently called The Birth Wars by Mary-Rose MacColl, which highlights the terrible relationship – the war – between midwives and doctors in Australia where tragic outcomes for women and babies have become a sort of collateral damage.  She doesn’t offer us any solutions but it seemed to me, since she called it a war, we can maybe learn something from the studies of soldiers who have been in combat.  I think the comparison is apt because they are both perpetrators and victims.

Judith Herman, who wrote the book Trauma and Recovery about the survivors of violence, political terror and sexual abuse, writes that every soldier has a threshold of resilience that can be exceeded fairly quickly:  most “tours of duty” exceed this threshold.  And given a horrific enough event,   no one is immune from the consequences of traumatization.   Judith points out that the trauma of combat takes on greater force when the soldier can no longer rationalize it in terms of some higher value or meaning.   Doctors like me feel a little bit this way when we question the evidence behind our practice.

There is a solution.  Herman also writes about the healing power of connection.  And so it is the connection that provides the recovery. It is disconnection, in some cases perhaps a merciful act of the brain to minimize memory of horrific events, which becomes the problem.  

Therapists say that when we make connections, whether it is in our relationships or in our professional lives, we can talk about anything.  What they don’t seem to talk about is the cost of connection.   Each of us needs to weigh in that cost.   If you disconnect, it seems that you will probably pay later: depression, anxiety, PTSD.   With connection, you pay now:  anger at everyone who makes the system suck for women. Anger at yourself for not being able to change it.

For me, one of the penalties in believing in women is to live alone in a world of wounds.  The choice is to harden my shell, or to make believe that the consequences of intervention and obstetric “scare” are none of my business[i].   I can’t seem to do either one.

 

*******

I am in the operating room, about to do a caesarean section.  The baby is exceedingly premature.

A paediatrician stands waiting to take him away.   The baby is breathing on his own, and very vigorous, and so, I say to the mother, go on, reach up and touch him, it is really important; they may not let you hold him for a while.  She reaches up and grabs his little foot in her hand, and afterwards I am sewing up her skin she is still looking at her hand and marvelling at the warmth of him, and how wonderful his skin felt. “He was hot as, cuz he came from inside me, and his skin was so freaky, soft,” she is saying.   But the anaesthetic technician has just noticed her fingers are covered in blood and amniotic fluid.  Frowning at me over the top of the drape, he hastily puts on gloves, and gets a bunch of tissues to wipe it away.  

 

 


[i] Aldo Leopold described this wounding from the view of an ecologist living a world of exploitation of the land, in his book, A Sand County Almanac  Oxford University Press 1949

*(of course, this is NOT even remotely okay)