As of last Friday, my obstetrics and gynecology rotation has come to an end, and as you've probably noticed, I've been uncharacteristically reticent to talk about it. Don't worry, nothing bad happened. As a matter of fact, in retrospect, this has been one of my favorite rotations. Scrubbing in on surgical procedures several times a week was an absolute kick and being able to act as first assist because I'd just completed surgery was like the icing on German Chocolate Cake. And, naturally, there were the babies. One, a few weeks premature, had the most beautiful, delicate, perfectly formed little fingers. Another fell asleep in the crook of my arm with her lips sealed against my left shirt pocket. No, darlin', I'm not mommy, but thanks anyway.
The truth is, I really had a wonderful six weeks and when it came time to leave, I felt almost as wistful as on the last day of my psychiatry rotation and that is saying something. What was holding me back from writing, though, took a few days to reveal itself, and unexpectedly, it did so in a dream. I was a student on the obstetrics unit in an unnamed hospital one evening, sitting on a counter ledge in the nursing station, watching a group of women. A few feet away on my left was a new mother breastfeeding her infant. Directly across from her, on my right, seated on a soft, pillowed couch, were five other women -- nurses -- mostly in their 40s and 50s. They were smiling and singing or chanting, I can't recall which, and clapping their hands in unison, swaying from side to side. I couldn't hear the words clearly, but they were obviously enjoying themselves immensely.
Everything was so totally natural no one, not even the woman breastfeeding, seemed even remotely self-conscious or uncomfortable because a man was present. I got up from my seat and approached one of the older women whom I knew well, just as the group stopped singing and began laughing, with the intent of whispering to her, "This is the first time I've seen breastfeeding have cheerleaders," because that's how it appeared. In the dream, of course, I thought this terribly funny and was sure she'd think it uproarious. It's easy to be Robin Williams in Dreamland.
What strikes me about the scene were the colors. Everything, including my clothes and those worn by the women, was done in shades of white. Not paper white, but more like the pastels used to depict heaven on film, with boundaries fading at the extremes and an absence of sharp lines. It reminded me of heaven as Maxfield Parrish might have painted it, ethereal yet earthly, mythic yet real.
It seemed to me, I was seeing womanhood in a way few have the opportunity. The women themselves knew this to be true and graciously permitted me a glimpse of the way they are privately, when they're amongst themselves. As a man, I wasn't exactly an outsider, but neither was I an initiate. I don't know what I was, a guest, perhaps? All I know with any certainty is, I was witnessing a young woman in the company of older women, all of whom having done as was she, feeding their children from their own breasts, and the feeling I had was of joy and serenity.
Rotations are about a lot of things, I suppose, learning and practicing new skills, adding to a growing body of knowledge, feeling more confident in oneself, but this one was far more. Frankly, I'm still having trouble putting it into words. I'll figure it out eventually; right now, I'm still in awe.
(Creative Commons image "White" by LaWendula via Flickr)
Five days ago, six if you count Monday and orientation, I walked onto the obstetrics unit, knowing little more than Prissy (Gone With the Wind, 1939), who freely admitted she knew "nothin' about birthin' babies." I guess that means I knew next to nothing, which is okay; if I knew at the beginning of this rotation what I hope to know at the end, there wouldn't be much reason for what comes along in between, would there?
As it stands, I've already learned a few things, among them that I'm not inclined to drop a slippery newborn despite the fact, as a kid playing Little League, "Butterfingers" could easily have been my nickname. There's something about holding a baby who's just taken its first breath, that makes you hold on for dear life. Maybe it's parenting instincts kicking in, but the thought of losing your grip doesn't cross your mind. Holding them close with a quick, welcome-to-the-world snuggle in the crook of your arm, while passing them to the NICU (neonatal intensive care unit) team, you bet, but letting them slide through your fingers? Uh-uh.
And then, there's the matter of learning about the mess. Childbirth really is messy business. Television prefers spit and polished, shiny clean new babies who don't make anyone squeamish. Not so Mother Nature. There may be some blood, especially if junior's exit from the womb produces a tear in mom's vagina. There's amniotic fluid when her water breaks, though that usually occurs earlier, unless she's having a C-section, in which case the flow of amniotic fluid is more like a flood. To top it off, there's meconium -- baby poop -- mixed in for good measure. Martha Stewart would cringe.
Honestly, though, I don't mind the mess. Life is messy. Personally, I think trying to eliminate the messiness nudges more people toward neurosis than the other way around. It certainly is a driving force in narcissism, where the appearance of perfection is all-important. Babies have an entirely different perspective. Forget all that other stuff, okay? Mom was toasty warm, will someone please wrap me in a blanket? Ah, there we go, that's better. Mm. Thank you very much.
What I'm particularly enjoying about this rotation thus far is the tacit understanding that some things can only be learned here. Internal medicine teaches you how to write a good clinical note, surgery how to behave in the OR, pediatrics how to deal with kids and parents, psychiatry how to manage things going wrong, and then rural and family med puts it all together. None of them, however, specifically target birthing, prenatal care, or women's health (gynecology). So, in a sense, it's expected that a student is literally starting over at the bottom. You can use skills gained elsewhere to a certain extent and yet, so much is totally new. Every day is pregnant (pardon the pun) with possibilities and you never know what's waiting behind door number three.
(GNU Free Documentation image of a brand new newborn via Wikipedia)
Today I delivered my first baby -- sort of. I had the guiding hands of a resident on mine and for good reason. I've read enough about damage to the brachial plexus (a web of nerve roots between the neck and shoulder that enable feeling and movement in the hand and arm) to know that the last thing I wanted was for this sweet little gal's arm to be twisted round with fingers bent as though she was a waiter expecting a tip -- because of anything I'd done. The tension distracted me from the elation I felt, but that doesn't change the fact that the hands that caught her were mine.
Ordinarily, fathers are offered the opportunity to cut the umbilical cord as we place the baby on mom's belly and witness the miracle of mother-child bonding take place before our very eyes. My baby, though, was a premie -- born a little too early and a little too small for her own good -- and destined right off for an appointment with the neonatologist, followed by a few weeks in the neonatal intensive care unit. Since dad was busy assisting his wife and timing was critical, I cut the cord and then we proceeded to deliver the placenta. My first time at bat and I have to swing at another pitch, but I'm not complaining, not one bit. I've been looking forward to this for a long, long time.
My imagination had this entire experience enshrouded in a mystical light accompanied, almost, by the voices of a heavenly choir. The reality was more sobering and it took me all day to put it together.
Delivering babies is something doctors do. I know, midwives do it, taxi drivers do it, policemen and sometimes fathers who can't get to the hospital soon enough, do it., too. Even though the division of medical labor results in many doctors only delivering babies during an OB/GYN rotation, as did I this morning, in my mind, being a doctor is still characterized by certain key tasks and delivering babies is one of them.
Whether I ever have the privilege of delivering another, I'll never forget this one nor will I ever cease to be grateful for the chief resident who stood behind me and said, "Go ahead, you can do this."
(GNU Free Documentation image via Wikipedia)
So, here I am, finally back home and it feels like a typical Saturday. The dog, cat, and I snug in my study by the fire and there's snow falling -- on the day before Easter. The fire is a necessity since the furnace tends to treat this end of the house like something to be avoided at all costs, but the snow was a complete surprise. Alas, it doesn't show in the photo -- so much for good intentions.
On Monday, my Obstetrics-Gynecology -- OB/GYN for short -- rotation begins at Maine Medical Center. In the meantime, my head is still revolving around pediatrics, an experience that turned out to be as surprising as this morning's snow. I had some contact with children during my rural medicine rotation, although not enough to describe it as traditional family medicine. It was mostly an adult practice, but what I learned applied to every age group. A physical exam is still a physical exam, whether the patient is seven or seventy.
One thing I noticed from my first day in pediatrics was how much more fun it was, working with kids, than adults. I mean, you can play with kids and they appreciate it, even when they're sick. That said, playing has a significance few realize: it's not simply about being charming or cute. And this is something I knew going in, thanks to a number of children who, over the years, have been willing to be my tutors. Play is the language children speak, particularly with one another, and not all adults are familiar with it.
I love words, written and spoken, their derivations, structure, the interplay of grammar and syntax that may span what we fear is an uncrossable abyss of hurt feelings, anger, and disappointment. I love it, too, when communication sidesteps the vocal cords and heart to heart is the dialect spoken eye to eye. Play is like that. When you let down your guard and become genuine with children, allowing yourself to be as vulnerable as they are, you make connections and establish rapport, sometimes without even saying a thing. Not unlike psychotherapy.
Before this rotation, I wasn't aware how essential play is for me as a clinician. I mean, I've always tended to joke with patients whenever it was appropriate because humor can be disarming; it creates a space in which we may be mutually human. But with children, it's not so much about creating a space as it is stepping into one that already exists, and the question becomes, can we forget ourselves well enough to become real with children, and believably so?
The hardest part, it seems to me, is relating to kids in ways they find meaningful and their parents endearing while maintaining an air of professional competence at the same time. It's one of those dance steps they don't teach in medical school. I suppose that's also why they call medicine a practice -- even on the best of days you're never completely certain you haven't tread on a few toes.
(Photo copyright 2011 by the author)
After-hours coffee and Danish from the Nook and Cranny had the earmarks of becoming a ritual between friends. Despite his pediatrics rotation having been complete around mid-September, Chuck continued drop by Bob's office throughout the first of his two required six-week internal medicine rotations and now an elective two weeks in radiology. On the other side of four more in OB/GYN lay psychiatry, at last. What he didn't expect was the residual effect of his initial month with Bob, Jessie, and the twins on his future.
"I keep thinking about that child-adolescent fellowship and it's all your fault," he said, hanging his head and faking misery.
"I've been blamed for a lot of things," Bob replied, ruefully, "including a baby when I was seventeen that I had absolutely nothing to do with -- and couldn't have even if I'd wanted to because I was on a Scouting trip during conception -- but this is a new one. Tell me."
They were sitting in Bob's office with their feet propped up on opposite sides of a massive roll top desk he'd inherited ten years ago from his pediatrics instructor who, at 80, decided it was a good time to retire and sail around the world. He made it, by the way, and now, he and his wife were trekking in Nepal, in celebration of his 90th birthday.
"Well, I thought I had everything planned out. Adult psychiatry was my bailiwick. Sure, I loved kids, just like you, but I enjoyed psychotherapy so much it was hard to see myself in another role. Then you came along -- and Jessie -- and the twins -- and the next thing you know, I couldn't get enough of pediatrics. Especially the kids with ADHD and parents who're going nuts trying to cope, the occasional bipolar disorder we've seen, and the substance-abusing teens. And frankly, I miss them. I feel like saying, along with the prophet Isaiah, 'Woe is me, for I am undone.'"
Bob pursed his lips and nodded, as though he had anticipated the news. "I had a feeling we were going to be a bad influence. It's even worse when the kids like you, and clearly, they do -- that's a trap waiting to be set. Top it off, when you can get teenagers talking -- well, all I can say is, you are in way wicked trouble, my friend." He broke into an appreciative smile.
"Looks like it. I don't know all the details yet, but I've got plenty of time -- see? You can't get rid of me, can you? Now, about the dream you mentioned a couple of days ago in passing, the one you had on the way home from Concord --"
"-- yeah, what did you think of that?" Bob asked, interrupting.
"It was a good one, especially coming on the heals of meeting Jessie's father."
"You're saying a dream's timing is as important as its content?"
"From the perspective of interpretation, yes. Dreams are one thing, the way we view them afterward, is another. My impression is, this one is suggesting you have your own rhythm. Kind of like Thoreau's comment, 'If a man does not keep pace with his companions, perhaps it's because he hears a different drummer.' In your dream, the bass drum was a stethoscope -- you're maintaining the 'beat' of the music all right, but in your way. Timing enters the picture because, from what you've told me about Jessie's dad, it sounds like he's inclined to do similarly. It's probably another one of the benefits of you being older, allowing the two of you to establish a more mature connection."
"I agree, but that didn't make it any easier. Sure, we were more likely to develop a peer-type relationship than would have been possible if I was nearer Jessie's age, but he's still her father and truthfully? I felt like I was 22 once again, sweaty palms included. I guess none of us are as 'together' as we'd like to believe."
"That holds true for me, I'll tell you. One thing you can definitely count on is your relationship with her father making life a great deal easier for Jessie."
Bob was in mid-bite on his Danish. He stopped, put it down, and said, "I would assume that's a 'given.'"
"It is, but there's more. It tells her she doesn't have to love one of you at the expense of the other. It gives her a deep, abiding sense of security about two of the most important relationships a woman can have with men. And a woman like Jessie, who clearly wants someone with more maturity than a guy closer to her own age might possess, has the unspoken expectation that whoever she brings home, should be someone her father can respect as well as one who respects him. You already know this, but she's really an extraordinary woman -- I hope I get half as lucky." With a gleam in his eye he added, "Wait a minute. Didn't you tell me she has a sister? Anyhow, looks to me like you hit this one out of the ballpark. When are you going to pop the question?"
Bob laughed, "One at a time. First, yes I did and she's available, but I think it would look better if Jessie played matchmaker. A professor setting up a date might appear as unfair advantage. As to the second, I haven't quite decided, but I'm thinking around Christmas. It's our favorite time of year and even a romantic moron like me can pick the right place. I need to find a ring and I haven't figured out how to get her size without coming out and asking. I could do that, I suppose, but then the cat would be out of the bag and I'd like this to be a surprise. Not that we haven't talked or at least alluded to it. I just want very badly for her to have the 'fairy tale,' you know?"
"Yes, I do, and she'll love you for it."
(Creative Commons image by Allie's Dad via Flickr)
I love going out for breakfast late at night. There's something about the witching hour that just makes bacon, eggs, hash browns, toast and coffee taste better. I got into the habit back in college when I was connected with a student group in my church. We'd go out after Sunday evening services and hit this one local restaurant like a ton of bricks. They served apple pie in a brown pottery bowl so deep you had to use a spoon.
Eventually, I made friends with a girl on the wait staff who was just as sweet. We never went out or anything, but it was one of those delightful, casual relationships you never quite forget. You know the kind I mean. Anyhow, one evening a couple of her admirers came in, wanting to chat, probably hoping for a date. The manager informed them my friend was busy and besides, she said, pointing in my direction, I was waiting to see her. Taken aback, they looked at me and asked, "Who's he?" It was one of those moments that makes a nineteen year old feel a little taller, better looking, and more sophisticated, even if he knows it's not really true.
It's almost springtime here on the farm, and I can smell the change in the air. The hayfield is nearly completely devoid of snow -- only a few patches remain along the eastern tree line where there's rich shade. The irises are starting to push up through the soil in the flower beds and I'll have to rake and spade soon. My predecessor, a retired OB/GYN doc, had a passion for English gardens and a green thumb to match. Horticulture is not my gift, but I'd like the place to look like someone still cares.
What does springtime have to do with food and old friends? Not a lot, except the onset of spring always makes me reflective. The newness triggers memories of things I've loved and either neglected or left behind. Books on the shelf beckon, despite the fact that I haven't got time to read the ones on my night stand. My guitars need restringing and I'm thinking about getting a second dog. Putting it all together might require some special planning, though, and for that I'll need fortifying. I guess I'd better find a place that serves a good midnight breakfast, you suppose?
(Creative commons image via Wikipedia)
I have a friend who has a favorite line from Gone With the Wind: "Miss Scarlet, I don't know nothin' 'bout birthin' no babies." Up until this morning I could completely identify with the character of Prissy: all I knew was what I'd seen on ER. A one hour lab session with a professional mid-wife has changed all that.
Using plastic models, we learned how to use two fingers to measure the dilation of the cervix, feel the fontanelles (spaces between an infant's skull bones that enable the skull to alter its shape during childbirth), and determine whether an infant was coming out head first (normal presentation) or bottom first (breach presentation). I know, plastic models aren't exactly the real thing, but it's a start.
It's an amazing thing to see, even in a protected environment, how we enter the world. I overheard one student comment, tongue in cheek, "I'm never having children!" I can hardly say that I blame her because it's a herculean effort on the part of women. But the skin and muscles of a woman's pelvis are remarkably forgiving and elastic. They have to be in order to allow an infant to twist and turn as it makes its way through the birth canal.
One of my partners was a new, first-time father who'd seen all this up close and personally, and his broad smile throughout the lab was clear evidence that he was reliving the birth of his daughter. I couldn't help but remember the young doctor played by James MacArthur in the 1960s film, The Interns, who rather cockily felt obstetrics was beneath him -- until his first childbirth experience, that is. I think we're all looking forward to obstetrics next year after this morning.
The complications that can occur are beyond us at this point in our education. We're just trying to get the basics right: put your hands here, don't push to hard there, ask if the mother is comfortable, don't pull on the baby, and so forth. It's not rocket science; it's more about being considerate and skillful, knowing when to ask for help and when to let nature take its course. In that sense, it's about life and the lessons we all benefit from learning.
