Malpractice lawsuits

I believe one of the most damaging things about these lawsuits,  is that they use our finely tuned consciences and our self-doubt against us. We need to be resilient, but not hardened. We need to CARE about our patients, not become hardened and suspicious and angered by their needs. We need to take risks to be able to solve their healthcare needs, sometimes we are uncertain, which is the actual real part of practicing medicine which doesn’t exist in the coding system. Gauging uncertainty and probability are the art of differential diagnosis. Patients respond differently to treatments. We need to keep having that tensile strength, and trust in our instincts and our medical acumen. Get help with counseling, to trust yourself and believe in yourself. We cannot control the outcome, we can only do our best to offer good care.

When Obstetrics becomes critical

The ethical fundamental rule in Medical Care is “First do no harm”. Second, is “DO good.” In the oldest human professional role, helping women to safely deliver their babies, we know that the first command is to save the mother, and then, IF POSSIBLE, save the baby.

Miscarriages occur in 20% of pregnancies, perhaps more. When they occur in the first 3 months, where there is a growing embryo, we understand that this is a life which cannot exist outside the womb. It cannot successfully be taken and planted elsewhere, like a good petunia! The development of the placenta is a complicated thing, and it carefully develops into an amazing life-support to the growing embryo, which then grows into a fetus, and at birth becomes a baby. In mid-pregnancy, the risk of miscarriages is often accompanied by life-threatening hemorrhage, because placental disruption is not complete, it remains partly attached and the blood vessels which were feeding it continue helplessly pouring blood into the open space in the womb. As the wall of the uterus continues to bleed, sometimes huge amounts of blood can be lost in a very little time. This is an obstetric emergency, and the uterus must be safely and completely evacuated so it can clamp down on the bleeding blood vessels. In centuries past, this was the most common reason for the death of a woman: an incomplete delivery of the placenta. Sometimes the bleeding slows, and it seems things will be ok. But if there is still placental tissue in the uterus, it still will intermittently bleed, and it also keeps the uterus from shrinking down to its normal size, with a tightly closed cervix. This puts the woman’s body at severe risk of life-threatening infection, (which used to be called Puerperal fever) and is now called Septic shock; and the mother must be given critical support of extra fluids, sometimes also transfusions of blood, and antibiotics to help control the infection. She may need to be in the ICU and need every kind of critical care support we can give. If she has lost a lot of blood before the antibiotics are given, it is harder for her body to muster the immune support to be able to overcome the infection, and she is at high-risk until the fever starts to subside and she begins to heal.

What has happened since the SCOTUS decision to reverse the national right to abortion and give the states power to enforce new draconian laws is very terrifying to those of us who are FIRST concerned with the life of the mother.

Reports are already coming out that in some places the hospital administration and sometimes medical staff are confused about our ancient mandate to take care FIRST of the mother, and then if possible, save the baby. If there is a heartbeat in an embryo or fetus, it still is not viable until it can live without the placenta, outside the mother. It is a miscarriage, and must be dealt with appropriately. God knows that this fetus is not salvageable. At some time in the future, we may have truly extracorporeal placentae, which will change the potential to save some fetuses, so we are not at the end of medical change and innovation which will help us have more choices. But right now, the baby’s heartbeat doesn’t matter, when this kind of miscarriage starts to occur.

We need to be prompt and clear about medical emergencies. An ectopic pregnancy is a pregnancy outside the womb, usually in the fallopian tube. The placenta cannot grow there, the wall is too thin. The mother is at risk of bleeding to death into the abdomen, if it bursts the tube and begins to bleed. It doesn’t matter if the embryo has a heartbeat, we cannot take this embryo like a little petunia, and put it safely into either a real uterus or an artificial one (yet) because of the delicacy and intricacy of how the placenta develops IN TANDEM with the wall of the uterus, which is going to work to pass food and oxygen to the developing embryo or fetus.

I am having nightmares about misguided protocols and delays in treatment of pregnant women having ectopic pregnancies or midtrimester (12-24 week) miscarriages. We need to make it crystal clear that the right thing to do before 24 weeks, is end the pregnancy by evacuating the uterus, so it can heal. There are some patients very close to 24 weeks with whom we can temporize and try to achieve enough time to strengthen the fetal lungs, to give it the chance that it may be able to live in the NICU for 3-4 months, and go home and grow up. BUT if the mother begins to have signs of infection she is at very high risk of Septic Shock, or Puerperal fever, and the answer is to empty the uterus regardless of the baby’s heartbeat. When this kind of tragic loss happens, we wrap the baby in swaddling blankets and let it be with the mother and father, until they are ready to say goodbye.

Thanks for listening to me on my soapbox!

Martina

Martina Nicholson, MD, FACOG, retired

Finding Balance Between the Law and the ethical concerns about Abortion                                  2022

by Martina Nicholson, MD

I am a retired Ob-Gyn, and a Catholic.  I majored in philosophy in college, and I have always had an intense interest in ethics.  I was trained to believe life is sacred, but I also watched my male college friends grapple with being sent to Viet Nam, for a war we did not believe was either reasonable or just; and at that time we grappled with “The Just War” arguments given to us, for consideration in trying to get an exemption for conscientious objection.  At the time, women were safe from the draft, so I did not personally have to consider being sent to fight in a war.   I also joined the Peace Corps right after college, and that also informed my sense of social justice.  The real limits of choices and moral distinctions for people,  due to poverty and unjust governments were very obvious to me, in my travels and life learning.

Since those early years, in which I was much more grounded in theory than in the problems of real life, I have come over and over to the problems in a crisis pregnancy, and what to do about it; what would be of best help to the particular woman, in this particular time.   I was often assisted in dealing with crisis in a particular woman’s  pregnancy by a supportive family; but sometimes, no community of advocacy and support was available.  This is the greatest heartache, and for the woman who is pregnant, the greatest need.   Love should be the context for a new life.   Support for the pregnancy and the emotional, spiritual and material needs of the pregnant mother must come from the people around her, the community.

We were taught in my philosophy classes,  to dislike the idea of modifying an ethical opinion for a particular situation.  “Situational ethics” seemed somehow wobbly and undependable.  I now think this is all that matters, to find the most ethical action in a particular person’s situation, and to try to help that person carry it out.  I think sometimes it is helpful to use the popular question “What would Jesus do?”   We know that the only people Jesus condemned were the high priests and religious lawyers.  He said “You whited sepulchers, you impose a heavy burden you yourselves will not carry.”  Everything Jesus did was based on love.  What he told us about the Father was all about love.  He did not bully anyone.  He said  “Abide in me, in my love, and the Father who loves me will come and abide with you, so that our love may be complete.”  Every human action he did was stretching out to do something for someone, with love.  Also, this is how rabbinical Jewish tradition works— to apply principles to the personal, individual life, with all that entails.    

It seems incredible to me that theology treatises did not start with questions about who you are, what family and gender you belong to, and who you love.  And most of all, do you have a Higher Power, loving and gentle, giving you spiritual strength and support to help you?   To be told that you are not allowed to love the person you love, or that God doesn’t want you to love that person, seems to me to be completely twisting the character of God out of all recognition from the one Jesus describes for us.  It destroys the internal radar of people,  who need to feel their Higher Power’s guidance and support as they take risks to grow.     

Motherhood is one of the ways we are called to grow much bigger than the self we are now… and we need help.  

And then there is history.  In Roman times, there were many virgin-martyrs.  This was not about sex, it was about the duty to the state, to have sons who would grow up to be Roman soldiers, to fight Rome’s wars.  Women who refused to marry and be pregnant were considered traitors to the state, and went to their martyrdom for treason.  The woman for whom I was named,  St. Martina, was one of these brave virgin-martyrs of the early church, around 300 AD.  They tried to burn her at the stake, but it rained.  They tried to get lions to tear her apart, but the lions sat down quietly.  So finally, they chopped off her head.  This gives poignance to the title of virgin-martyr.

So what I now think about the right of the state to protect the unborn is complicated with the question of the right of the state to send that child after it is reared, to be a soldier for the state.   Since Dorothy Day, I think there have been legitimate questions about whether ANY modern war can be considered a just war.  More and more, the wars we have fought are to get oil or natural resources away from a different country.  Many of our wars are to topple governments which actually were “the will of the people.”  The story of Viet Nam, and the role of Ho Chi Minh after WWII is instructive.  And this foreign policy twisting goes down to what we are now doing in many countries with precious metals and natural resources we covet.  And possibly the instigation of nuclear war, which could quickly escalate to nuclear holocaust, if not the end of life on Earth.  All for reasons which have nothing to do with self-determination as a people.  

My belief is that the life in the womb is important, and that the woman who is becoming a  mother is also important.  She is not just a carrier, but a human being,  and her natural dignity and worth do not depend on motherhood.   Her talents, her desires for her own life, and the partner who helped to conceive this child also matter.  God has given her life, and her life also should not be narrowly construed or devalued.   The life in the womb is organic, and grows to become a child.  Any limit—- any attempt to find a place that one’s ethical rule for cut-off can become categorically clear— is not possible, in this continuum, I believe.  It is not that it is a pre-child one minute, and a child the next minute.  God brings new human life into the world through women and pregnancy in a continuum of growth and development.  So, trying to nurture and protect the process  seems reasonable and important, and part of our duty to God, as much as stewardship of the earth through being good gardeners and good farmers.  We have a saying in our field of obstetrics, based on data, that $1.00 in prenatal care saves $3.00 in pediatric care for premature or unhealthy babies.  

Protecting the stewardship of fertility also means making it possible for women and couples to be able to use whichever means of family planning will best fit their needs.  This individualizing is part of conscious use of our minds and personal and social ethics, as well as medically safe methods.   

24 weeks is the currently the beginning of possibility of life outside the womb.  Before that, the lungs are not developed enough to hold air and pass oxygen to the blood.  Even if you try to put a tube into the infant’s airway to help it breathe, the lungs cannot fill yet.  Before 24 weeks, it is technologically not yet possible to help get the lungs to fill.   This may be the source of some people’s concern that a very premature baby is “gasping for air” and the doctors are not trying to help save it.  The instinct to gasp for air is there, but the lungs are incompletely formed; they are more like liver tissue, than the honeycombs of lungs, with pockets for air.  It is like a butterfly being torn too soon from the chrysalis, and unable to fly.  There are stories of babies born below 24 weeks who make it through the months in the NICU to become capable of leaving the hospital.  Most of them probably have been wrongly dated in the length of their gestation.  Yes, miracles do happen, but they are very rare.   Another situation is when the fetus has no kidneys, so that it will not be able to live without dialysis all its life.  These fetuses often also do not have full lung capacity, and also may “gasp for air” as a reflex, even at later gestational ages,  but attempting to resuscitate them is usually unsuccessful.  Neonatologists are educated in fetal anomalies, and are aware, when a lethal anomaly is present, that it is not “life-enhancing” to try to give full resuscitative care.   Neonatologists are also now required to give parents a realistic assessment of the chance for the premature infant at this gestational age to be able to grow up, and become a child with full capacity.  The earlier the premature fetus is born, the higher the risk for lifelong disabilities, especially cognitive delays and impairments. 

Because of this, most hospitals which do not have a Tertiary level NICU will send the pregnant mothers  with very premature impending deliveries, to the nearest Tertiary care center, before the delivery, if possible;  in order to give her the appropriate counseling, and to help the baby be born in the best center to treat extreme prematurity if it is viable. 

Recently there was a poll taken that 76% of Americans would like to see abortions limited to under 12 weeks.  The problem with this, medically, is that lethal anomalies may not be detected with ultrasound scanning,  until 18-20 weeks.  Such problems as anencephaly, or severe cardiac malformations, or absence of kidneys, may make the ongoing life of this fetus seem an unbearable burden to some mothers.   

Medically, also, a mother may develop a serious medical condition which threatens her own life.  Cardiac problems, severe kidney disease, or cancers are among the conditions which may make it necessary for a mother to consider termination of pregnancy.  In these cases, there are Ethics Committees in hospitals, where doctors and a team of people help to discern what is the best possible answer in keeping with the beliefs and concerns of the mother.  If a mother with a medical illness needs to terminate a pregnancy, her very life is at stake, and she must have the best possible medical care during and before and after this procedure.  The abortion must be done by one of the most skilled surgeons.  Problems with cardiac output and blood clotting disorders make the procedure even more dangerous, and if the mother does NOT have the procedure she also might die.  These women need to be given the best care we can give them, and often, also to endure the heartbreak of losing a desired child is an added trauma. 

If a fetus is born before the 24th week, in most places with a sophisticated NICU, the parents are given the choice of comfort care.   When the preemie baby is born, the pediatric neonatologist determines clinically, whether there is potential for life-outside the womb, whether there is a chance for resuscitation to be successful.  If the mother has asked to “do all possible” and there is potential for viability, in a tertiary care NICU, this help will be given.  But if the fetus is insufficiently mature for the resuscitative efforts to be of any use, the parents will be counseled that comfort care is “the best thing to do.”

The baby is wrapped in warm blankets and given to the parents to hold.  Most physicians believe this is the least traumatic and best way to serve families with the difficult and painful loss of a very premature infant. 

We have 60 years of data that millions and millions of women and couples have been able to successfully plan families and carry these families healthily, with smaller human families being the norm.  Being able to feed and clothe and house the family is a normal part of the duty and desire of parents.  Choosing how many children to have, and trying to choose what an optimal time is, for when to have children, is also a reasonable and wise part of stewardship of God’s gift of fertility.  

We would not want farmers to ignore the weather and the needs of their land in planting crops.  We want our societies to be stable and our families to be sources of love and mutual support and care.  Using scientific technology and birth control methods which have been shown to be safe, effective and helpful for couples in planning families is sensible.  I have been waiting a long, long time for the reversal of the ban on contraception, by the Catholic Church, which has cruelly treated women and couples  (who have been prudent and modest in their desire to raise healthy families), by saying that the Church thinks it is sinful, and implying that God doesn’t love you if you are using birth control.   

For some people it is impossible to see that this is a bullying position, not one which actually allows  freedom to the couple to choose what is best for them.  At least in theory, the Catholic ethical position is that God has given us freedom of choice.  We are to be allowed, (even encouraged!), to exercise our consciences, in living.   Jesus said “I came that you might have life, and have it more abundantly.”  He did not say women had to have as many children as the body can bear.  He did not say that men have the right to rape women, or force women to carry more children.  It is interesting that Mary his mother, only had one child.  This is a model which is even more helpful now, as human population burgeons all over the planet.  

So, over time we have to keep asking ourselves, what is the right answer, about abortion, and why.  We are a political society and a land of multicultural diversity.  We have laws which enshrine the belief that all people are equal and that we are a country based on the rule of law.  

I think we have to take into consideration that ethically,  in medicine, the primary priority is autonomy.  

In political society, I believe the proper ethical role of the church in our country is in moral suasion, rather than forcing or bullying women to carry children.  

And that leaves us with what should be legal.  I believe abortion should be legal.  I believe we need to protect the physician’s right, to not do abortions, and to do them, without legal sanctions, and without criminalizing either the doctor or the patient.   There is no middle ground ethically, to reconcile people who think pregnancy is sacred,  with people who think the right of the woman over her own body is sacrosanct.   I believe we have to let women choose whether to continue a pregnancy.  We can try to persuade a woman that it would be better to carry this child, and we can try to make it more bearable for her by helping her with her other corporal needs;  housing, food, safety, healthcare,  the means to exist as a parent, and also in dealing effectively with possibly violent or cruel people who surround her. 

Our proper role is to help women grow into mothers, by supporting them emotionally and spiritually, and as concretely as possible, as they take on this task.  No woman feels completely ready or capable of becoming a good parent, her self-doubt can be excruciating.  And helping the women with their needs in pregnancy is the proper role of the family and community.  The community becomes even more important when the family cannot meet the woman’s real needs. 

If you ask “Who is the advocate for the unborn child?” it is the family, the community, the people surrounding the pregnant mother.  The natural best advocate would be the father.  But some men do not take the role of fathering as a sacred trust.  Others are incapable.  Some families cannot be supportive.  So the community becomes the support for the woman in a crisis pregnancy.  This is NOT the state.  It is more variable, more fragile.  But it is REAL, and it understands that a child will need more support and advocacy as he or she grows.  For someone to insist that the federal or state government take on that role is unrealistic, I think. 

The highest amount of domestic violence is aimed at vulnerable pregnant women.   Many women seek abortions because of rape, or incest, or partners who are violent or addicted to substances which make their behavior cruel, life-threatening, and unpredictable.  Women want to be able, when bringing a child into the world, if possible, to give the child a stable home.  We should applaud this instinct in women, instead of condemning it.  For some women, their own parents and family can provide that safety and home, allowing her to get on with her life as a single mother.  Some women are dynamic and courageous enough to work through all the vulnerabilities of being a single mother with almost no social support.  But not all women have that ability and strength.  

If the society and the church community wish to be of service for women in crisis pregnancy, they will be more creative, finding ways to support pregnant women with housing and safety and medical care.  

The mandate for the Christian community is TO LOVE.  We love each other by providing for the needs of each other.   The society at large also DOES have a stake in the healthy raising of children.  We now have 20-25% of children being raised below the poverty line, often in unsafe housing and unsafe situations.  This is compounded for mothers who themselves are afflicted with trauma, mental illness or addiction.  And it is severely complicated with fathers who are violent, drug-addicted,  or locked up in prison,  and so are unable to be helpful in real time to the mothers and children.   Also we have to come up with practical solutions in situations of unsafe housing,  and for communities without adequate safety for children and families from ongoing violence.  The USA is now considered one of the top 10 places in the world for violence against women to occur.  Women and children refugees and homeless people needing shelter are even more vulnerable to violence; abuse, rape,  torture, human trafficking, and death. 

In the long run, I believe we will do the best we can with the difficulties of crisis pregnancies if we confine the actions of the Christian community to trying to LOVE instead of bullying women.  

And in our national laws, we will do best by protecting the women’s right to pregnancy terminations.  

As the science and pharmacology of Medicine evolves, new methods and more effective methods of family planning which are safe for women’s health have come and will keep coming, and we should do our utmost as a society to make these methods available for all women to use and to choose.  The current most useful tool for abortions in very early pregnancy are medications which detach the placenta from the wall of the uterus, and lead to a miscarriage. By giving women and couples the right to decide what is best for their own families, we put family life on the surest footing. This also leaves up to conscience the decision which is proper to the person, and not reducible.

In the rest of the world, and before the advent of modern contraception, the only real means to solve overpopulation were war, famine and plague.  But now we have medically safe and prudent ways to help families, to help make childbearing and child-rearing the best it can be, in spite of all the difficulties, risks,  and uncertainties of modern life.    For those who think this is not pro-life, I reply that we also allow capital punishment and killing in war, in spite of the 5th commandment, which has no sub-clauses.   God knows the amount of slaughter going on in the world, and how many millions of children die of hunger, malnutrition and curable diseases due to lack of access to medical care.  

What we should be striving for is TO LOVE.  Jesus’ mandate, and his message was pretty clear– “this is how people will know you are mine, that you LOVE ONE ANOTHER.”

The Anthropology of Affliction

 I have had to grapple with the image of such a magnificent human being, most of my medical life.  I couldn’t be what he was.   He was stellar in every way.  He could function on almost no sleep, and had the vise-like grip of a photographic memory and the ability to brilliantly work out both diagnosis and treatment plan while holding the patient’s hand and asking them what they ate for breakfast, and who took care of them and brought them to the clinic.  And also figuring out how to get the medicine he intended to prescribe delivered to the patient.   He understood poverty and illness, he understood that the sick are poor, and the poor are sick. The book Mountains Beyond Mountains, about Paul’s life, came out in 2003. I was in the Peace Corps in South America from 1972-74. I started practicing OB-Gyn in 1990. I did not have his personal charismatic model or his ability to use the language of liberation theology in the early years. But once I knew about him, I knew he existed, and that his way was TRUE. It was ballast against all that is wrong in medicine, and all the barriers society sets up. I truly hope, as did his college roommate John Dear, that he is canonized, and also named a Doctor of the Church. Because he changed the world! And he did it like St. Francis did– with love and joy, not out of a sense of duty. I loved that he said he could sleep when he got to Cuba, because everyone there had a doctor. Having a doctor you could call on was the gist of what he wanted to make possible. And a good doctor, who wanted to save your life, with dedication and compassion.
He grew up in poverty, living on a bus his dad drove around,  for a lot of his childhood.  That he made it to Duke and then Harvard was a miracle.  He didn’t get to go to Vienna.  He didn’t study music or go to the opera.  His friends were the best in each field, and the most creative minds in our time, full of passionate energy.    
But we are not called to be who he was, we are just called to be inspired by him; to allow what he showed us about how we could be more fully human, more engaged and compassionate.  One of the most poignant chapters in Mountains beyond Mountains is when he marries Didi, and they have a child, and he says to himself that he must not love his own child more than all the children he has cared for.  He grapples with the limits of how much we can love, and whether we can morally love our own families more. And I learned from that question that we all have to love whom we love, the best we can.  Simply trying to do the best we can, without judging ourselves, without torturing ourselves with questions about quantity and quality.  I think his faith was what gave him the ground for those decisions, to just do the best we can.  Putting the outcome in God’s hands, but doing the best we can.  He didn’t waste time with second-guessing and self-doubt.  He understood very truly the limits we all have to function within.  He had enormous energy, and some people don’t have even a quarter of what he had.  But they are just called to be who THEY are, not to be something different.  That was part of his brilliance.  Jim Kim was a strategic systems thinker, and he could see the way through, to get the medications made in a less-expensive way.  He wasn’t focused on the individual patient the way Paul was, and it was brilliant that he did what HE could do to help.  It changed the world!  

Paul inspired each person to give what they could give.  It was like loaves and fishes, in so many ways.  Here is the poem I wrote about the work Jim Kim MD did in the Siberian prison camps, where both TB and AIDS were rampant, and the Soviets didn’t want to have to spend money to treat prisoners. A travel fluke made him have to deal with the Russian generals, instead of Paul. He had a karaoke machine, and he sang to them!

THE SNGING GULAGMEISTERS

(For Jim Kim, MD)

They were swilling vodka

And cared nothing for the Siberian prisoners.

It was winter

Like Varykino in Doctor Zhivago

Snow-lace and bear rugs

Wolves howling in the foothills.

He brought out the karaoke machine, 

And hoped for the best;

Flushed with vodka, 

Singing “My Way” with the Sinatra swing.

While spreadin’ the news,

Death and dyin’;

Grim not glamorous;

Siberian prisons

Full of T.B.

He wanted to treat the prisoners

On behalf of mankind, 

He sang to the generals.

Men in olive drab,

With chests full of medals

And flushed cheeks

Began to join the minister,

Whose clear baritone

Led them in a Russian ballad, 

Answering song for song;

And a miracle happened.

They said yes, 

To this most improbable idea;

Treating the prisoners with T.B.

In the gulags, 

Something good for this Earth.

Published in 2007, in Walking on Stars and Water, by Martina NIcholson MD

(available on Kindle, or contact me for a book)

THE DEATH OF THE MANGO LADY

(FOR PAUL FARMER, MD)

The ladies in the little overturned truck

Spilled like mangos onto the road.

The mangos, in rainbow sherbet colors,

Like sunrise and sunset in Haiti,

Spilled out all over the road,

Spilled and splattered open,

Their soft apricot and coral juicy flesh

Sweetening the dust,

A whole months’ wages lost.

Grangou, grangou:  hungry children

Scrambled to retrieve the unbroken ones;

And the mango ladies

Holding their moaning mouths

Watched

The driver lay a piece of cardboard

Over the body of their friend,

Her legs and feet still uncovered.

Surrounded by mangos,

An altar offering– 

Fruit of the world, 

Suffering of the world,

Women on their way to market
Waylaid by death.  

Squatting by the roadside,

Watched by the hungry children,

Moaning;

Stopping the rhythm of daily life

Trying  to get enough

Food for the children;

Stopping to grieve,

Broken open 

Like sunrise and sunset

All over the dusty road.

Published in Walking on Stars and Water, 2007, by Martina Nicholson MD

DONKEY AMBULANCE

(FOR PAUL FARMER, MD)

Whimpering whispering,
”I am sick, I am hungry”

 Rises like steam from 

The not fast ambulance, as it  

Comes toward us with the child-woman 

Groaning and vomiting,

Feverish and swollen- bellied,

Father and brother and spouse 

Walking alongside the narrow pallet. 

No one is sure whether she can be saved,

No one is at all sure

Whether there was sorcery

Or bad luck,

Or what is happening to her.

The donkeys plod along

Pacing themselves on the road.   

I think it is appendicitis,

I think she needs surgery,

I think and say, “bring the lamps”

Get her onto the table,

Call the operating team.

She is moaning,

Her lips are trembling and blue,
I am still listening

With total concentration

To her belly; as I bend over with

My forehead pressed to the fetoscope, 

Listening for the tiny thump-thump

Quick- paced rhythm of a fetal heartbeat.  

The donkeys stand.

They stand with their heads lowered,

Patiently,

Waiting for someone to feed them.  

Published in Walking on Stars and Water, 2007, by Martina Nicholson MD

THE ANTHROPOLOGY OF AFFLICTION

(FOR PAUL FARMER, MD)

Poverty and AIDS;
While standing at the blackboard,
What I was going to say before I heard
That hacking Tubercular cough from 
That hungry skinny patient,
Leaning down, squatting against
The filthy wall in this clinic
With Mother Hubbard’s cupboards.

People in the first world keep talking about choices.
These people have no choices;
Ignorance and hunger and sickness
Are their daily fare.
Grangou, grangou.
Hungry, hungry.

Here there is no way to hide
With existentialist bullshit
The truth about the hunger.

AIDS is the lurking shadow
If you sell for a pittance
The access to the vagina
Just to be able to feed the hunger.

My mind goes around the mouth
Around the vagina
Around the swollen belly
of the kid in the middle of the room.

What I was going to say
Before:
About affliction
About choice, 
Getting swallowed up in the hunger. 

Published in Walking on Stars and Water, 2007, by Martina Nicholson MD

A reflection on Pregnancy Losses

One of the puzzles in life is why people have been so reticent to talk about miscarriages.  They occur in 20% of pregnancies, usually before the 10th week.  Most of the times, now that genetic studies can be performed on the fetal tissue, it is due to a congenital problem which stops the growth, makes it impossible to go on.  Like a house which is being built, where the plans are missing several pages, the process has to stop. Sometimes it is about the heart or the kidneys or the lungs. Some miscarriages occur much later, with those organ-system “birth defects”.  And some babies do make it, which sometimes leaves them with a crippling problem, but alive.  Did you see the movie “Crips”?  It is great.

The general reticence to talk about miscarriages also applies to a lot of medical complications, and even cancer and other life-threatening illnesses.  Secrecy is just one of the ways people try to limit having to talk about the pain they are feeling.  The vulnerability can be excruciating. And some families feel that sharing vulnerability is a cardinal wrong–they think of other people as “outsiders”—  and say “it is none of their business”.  They do not expect others to be a source of loving support and compassion.

My husband was in severe pain about our miscarriages, but had no language to be able to talk about his pain.  And he believed in secrecy. It was excruciating.  

Until we had ultrasounds and genetic testing, most people’s questions about WHY were unanswerable.  Sometimes it is about the way the uterus is formed, but often it is about going into premature labor. Sometimes, in the early 20th century, uterine suspension was prescribed, which is using stitches to hold the uterus up, like a half-inflated balloon, instead of letting it fall over on itself, bent, which might put early pressure on the cervix to make it open too soon.  

In my case, I was 37 when I got married, and I had the first miscarriage at almost 39, and then Andy was born when I was 39.  Then I had 4 more early miscarriages, before the 10th week.  In each case, they had looked good on the first ultrasounds.  Doctors think there is more likelihood of miscarriages with advancing age in the mother, (due to older eggs) so that was what we thought mine were due to.  It is hard to have the courage to try again, but we so deeply wanted children, we had to try.  Sebastian was born when I was 41and a half.  I never was able to conceive again.

I was grateful for a program of healing at my church, which did a guided imagery and blessing.  The guided imagery was to go see these babies who had gone to heaven.  We can not tell before at least 12 weeks whether it is a boy or girl, because on ultrasound the genitalia are ambiguous until then.   So I don’t know about the genders of my lost babies, but I gave names to them all, and one is buried in the back yard at the grandparent’s house, because I was allowed to take “her” home.  I had this lovely time, with all of them having a picnic with me,  healthy, apple-cheeked, busy children, playing under a big oak tree, on a sunny day.  And then the priest asked us to give them back to God, in heaven, and let them know we will see them again there.  This was a very healing thing for me.  It is very hard to lose a wanted child, even this early in pregnancy.    

I felt that I was given this lesson 5 times  in order to really have compassion and understanding for the pain of my patients;  not just say “oh, its a miscarriage”.  There are women who are so traumatized they won’t try again, and some won’t ever even have sex again.  Some men also, back away from the kind of suffering it causes; the risk of those months that parents hung an ornament in the shape of a stork on the Christmas tree, symbolizing their hope.  Learning to talk about it really matters, and we can now help a lot more, give answers and sometimes real reassurance.  It is also important to let people know when we are in early pregnancy, because there is a risk the pregnancy is NOT in the uterus, but in one of the tubes, which is called an ectopic pregnancy, and it can kill a woman, because all the bleeding is hidden inside the belly, when it ruptures.  It is a surgical emergency.  

One of the miscarriages I had occurred when I was 3 hours away, visiting my sister.  I started hemorrhaging.  I packed myself into the car with a lot of towels between my legs and under me, and drove straight back to my own hospital, and got into the ER, spilling clots and spatters of my blood all over the place,  and begged/demanded for them to get the resident on call to do a curettage (cleaning out the uterus) because I was bleeding so much I knew I would need a transfusion if they didn’t hurry.  

The uterus cannot clamp down and stop bleeding until the embryo or fetus and the placenta are out.  Sometimes the placenta doesn’t separate cleanly from the wall, and the walls just keep bleeding profusely, until the uterus is empty and can close down.  Sometimes the muscle is too inflamed or infected to close down effectively and we need a lot of medicines to  help strengthen it, to stop the bleeding.  This is one of the reasons I have fought my whole life to get universal healthcare.  Women need to be able to get into the ER and have care for a miscarriage like this.  

This is the main job I did for a long time— to try to stop the uterus from bleeding, after a baby was born, or after a miscarriage.  In third-world countries this is the common highest risk reason for mothers to die.  

I have a deep attachment to the cup at Communion, that it is the blood of Christ.  There are times when all I could think about was blood.  It is good to connect to the life-saving potential of blood, and the soul-saving potential of Christ’s blood.  It is wonderful that the actual symbol is wine.  Wine which is love and blood.  Perhaps this image has helped me, to hold on to the faith that there is spiritual growth possible, even in these painful losses. There is nothing so wonderful as a baby, for bringing us hope for the future, and bringing the love both from us and to us, in a family. And it was my privilege to help many moms and dads make it safely through that process, to arrive at the joy of having a newborn baby in their arms!