THE STORY OF ONE PREGNANT PATIENT & THE APGAR SCORE

 

THE STORY OF ONE PREGNANT PATIENT & THE APGAR SCORE

Virginia Apgar

Writer and physician Atul Gawande, reminds us in his book, BETTER, that much of modern medicine did not just happen—it came to be through trial and error, through the deaths of others, the mistakes and triumphs that IS the history of medicine. In BETTER, a surgeon’s notes on performance, we meet Elizabeth Rourke in the chapter, THE SCORE.

OUR PREGNANT PATIENT

Rourke is forty-one weeks pregnant, having contractions. She’s an internist, on staff at Mass General. Her contractions are 7 minutes part. She reports this to her obstetrician at 8:30 am. She is told not to go to the hospital until her contractions are 5 minutes apart. Standard protocol. (this book was published in 2007). In medical school, Rourke has seen fifty births, delivered 4, and watched one in a hospital parking lot. It was winter, the baby was blue, crying. They covered the infant, raced back into the hospital. With that memory, Rourke finished packing her bag and her husband drives her to the hospital.

SOME HISTORY

Gawande then relates some history of pregnancy and birth that has been recorded. He writes of 21-year-old Princess Charlotte of Wales, in 1817, four days in labor, struggling to deliver a nine-pound boy in a sideways position, his head too large for her pelvis. When he finally emerges, he is stillborn. Charlotte dies six hours later from hemorrhagic shock. Gawande relates that her physician was reviled for not using forceps. In remorse for her death, he shot himself.

Gawande relates other statistical history of births—that in 1933, the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth in New York City. At least two-thirds of those deaths investigators found to be preventable, that many physicians simply did not know what they were doing. They missed signs, symptoms, incorrectly used forceps and spread infection. Midwives did better.

UPDATE ON OUR PATIENT, ROURKE

Her pain has increased, thinks she must be 7-8 centimeters. She is at 2. Her labor has stalled. Then at 2:43 AM she is at four centimeters. It’s been twenty-two hours. They give Rourke an epidural. This is not a simple procedure. Gawande goes through the steps, explaining the risks, one being the mother’s heart rate dropping and the necessity for a bolus of fluid injections and ephedrine to increase and stabilize hers and the baby’s blood pressure. The baby’s heart rate is being monitored constantly, showing decelerations during contractions and then recovering. When necessary, Rourke (and thus the baby) are given extra oxygen by a nasal prong.

At 6 AM Rourke is a 4 centimeters. At 7:30 Dr. Alessandra Peccei comes on duty. Rourke is 6 centimeters dilated and 100% effaced. Baby is seven centimeters from crowning, head becoming visible at the opening to the vagina. As the hours progress, Dr. Peccei punctures the membrane of Rourke’s amniotic sac. Waters flow, contractions pick up, the baby does not move and the heart rate begins to drop. 120, 100, 80. When the doctor stimulates the baby’s scalp, the heart rate responds.  

SEGWAY to: VIRGINA APGAR, the APGAR SCORE

Virginia Apgar was a doctor working in New York, a doctor who had an idea, one that Gawande states is “ridiculously simple.” It transformed childbirth and the care of newborns. And as Gawande states, she was an unlikely revolutionary for obstetrics, had never delivered a baby, not as a doctor, not even as a mother. But she would often sit down with someone having trouble and say, “Tell Momma all about it.” She was a surgeon, but joined Columbia’s faculty as an anesthesiologist. She became the second woman in the country to be board certified in anesthesiology, helping the practice to have its own division, on equal footing with surgery. Gawande writes that Apgar was appalled by the care many newborns received.

“Babies who were born malformed or too small or just blue and not breathing well were listed as stillborn, placed out of sight, and left to die. They were believed to be too sick to live. Apgar believed otherwise. She had not authority….She was not an obstetrician.  She was a female in a male world. Gawande: “So she took a less direct but ultimately more powerful approach: she devised a score.”

The Apgar score—as it is now universally known, allowed nurses to rate the constitution of babies at birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good vigorous breaths, two for moving all four limbs, and two if the heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.  

RESULTS 

Throughout the world, virtually every child born in a hospital came to have an Apgar score at one minute after birth and then again at five minutes after birth. It became clear that a baby with a bad Apgar score at one minute could often be resuscitated, with doctors, nurses providing warmth, physical touch and oxygen, to help the baby gain an excellent score at five minutes.

The results: neo-natal units! The score also affected the management of childbirth. Spinal and epidural anesthesia were found to birth babies with better scores than general anesthesia.

Prenatal ultrasound became a regular process used to detect problems for delivery in advance.

Fetal heart monitors became standard. All these changes, these procedures have produced amazing results. Gawande writes: “In the US today, a full-term baby dies in just one childbirth out of 500, and a mother dies in less than one in 10,000.”

FINAL THOUGHTS    How did Dr. Apgar’s work make doctors BETTER?

The Apgar Score changed everything, being a practical way to calculate and give doctors an immediate feedback as to how effective their care had been.

The Score also changed the choices that doctors made concerning how to do better! They poured over the Apgar results, wanting to encourage results that would make every doctor, nurse, from the most experienced to the novice, a better practitioner.

And our patient, Elizabeth Rourke? She had almost 40 hours of labor and finally a Cesarean section. Katherine Anne was born at seven pounds, fifteen ounces, brown hair, blue-gray eyes, and soft purple welts where her head had been wedged sideway deep inside her mother’s pelvis. Her Apgars: 8 at one minutes, 9 at five minutes—nearly perfect.

MORE TO READ: Find more wonderful information about Health Care in Gawande’s books: BETTER: A Surgeon’s Notes on Performance, COMPLICATIONS: A Surgeon’s Notes on an Imperfect Science, BEING MORTAL: Medicine and What Matters in the End, THE CHECKLIST MANIFESTO: How to Get Things Right 

I’ve read them all.

 

My INDEX TO AUTUMN

 

My INDEX TO AUTUMN

DEFINITION of INDEX: an alphabetical list of names, subjects, etc.,  typically found at the end of a book.

AFTERNOON: angle of light in; soccer games in; time to rake leaves, walk in;

APPLES: bobbing, drying, picking; for pies; green, red, yellow; teachers dislike for–truth revealed;

ARGUMENTS DURING: regarding football games on TV, leaf raking;

BABIES: record number conceived in; riding in strollers for walks;

BASKETS Of: apples, cinnamon bread, dried flowers, pumpkins;

BIRDS: departure of; feeding with break crumbs, pumpkin seeds;

BLANKETS: washing, adding to beds, especially in colder climates;

BOTTLES: contents of: cider, wines, window cleaner;

CANDY: see cavities;

CAVITIES: see candy, Halloween;

CHILDREN: arguments concerning leaf raking, trips to ER after football, soccer games;

CORN: husks; stalks in fields; sweet with butter;

CROPS: abundance of; ruined by rain/winds; varieties: cranberries, melons, pears, yams;

DYING: sunlight along the grass; light in the tops of the trees;

FOOTBALL: games, scores, tailgates; see also arguments about…

FROST: first; preparation for; harm to delicate plants not covered; see cultivars;

GRAPES: arbors of; jams, jellies; wreathes made from branches of;

GRASS: color of; reduced growth of; spreading roots;

GREEN: grass after rainfall; see photosynthesis;

HALLOWEEN: cornstalks; costumes; light on the night of; rain on the night of; scarecrows; tricks by children; See shaving cream, toilet paper;

HARVEST: moon;

HUSBAND: arguments about football games and raking leaves;

INDIAN SUMMER: stories, length of; discussion as to whether term is politically correct;

KILLING FROST: see frost;

LAWNS: covered with leaves; light from sun in late golden afternoons;

LEAVES: gold, plum, red, yellow;

MOON: harvest; full; lover’s moon; yellow; zenith hour;

PHOTOSYNTHESIS: cessation of in plants;

PUMPKINS: carving of; orange; size; transformation; See husband, children;

RAKE: varieties: bamboo, iron; plastic; verb: arguments pertaining to…

SLANT: of sunlight;

SQUIRRELS: everywhere; eat Indian corn off porches; bite into pumpkins;

SUNSETS: amazing…

TEENS: hanging in groups; homecoming; tricks on Halloween; football; testosterone;

TESTOSTERONE: see babies, teens; parenting;

WASHING: see windows;

WELCOME: see wreaths for doors;

WINDOWS: see washing;

WREATHS, on doors: corn husk, grape vine, soon to purchase evergreen; also, wreath of smiles. Autumn is the loveliest month.

Thanks for reading. This was written when my children were young. I save everything.

THANKS FOR THE GORGEOUS PHOTO FROM: Scattered Thoughts and Rogue Words  

Relax, Let Go, There’s Goodness…

Relax, Let Go, There's Goodness...

How do you let go of stress? Do you walk, run, indulge in a hobby?

I’m a gardener, but I do love autumn, appreciate the end of things, the respite. I could say I just need a break, but because of the many things & duties we take on in our lives, it’s good to anticipate some letting go, to be creative with how we use that freed up time.

LOOK TO THE SEASONS

After our wild fertile spring blasts her seeds, creates weeding headaches, I truly don’t mind a halt to that growth, to the gradual letting go as the earth grows cold and the sun’s angle changes. Autumn is when flowers stand out against the returned vigor of green grass, the shouting changing colors of the trees. Being outside on a warm day becomes a gift. I soak up the sun, become even more aware of the beauty of the earth, as I rake, pick the last flowers in the garden, put away flowerpots. Because I am preparing my garden and myself for the onslaught of winter. As folks like to say, IT’S ALL GOOD. But it is major change.

CHANGE: SOMETHING WE CAN’T ESCAPE 

The cycle of the seasons affects many things in our lives: school ends in one season, begins in another. Jobs and job responsibilities cycle throughout the year. Our very existence can change from the height of abundance to the depth of loss. But change is inevitable, and in these past seasons dealing with COVID, loss and gain have been the primary struggle. So are you okay? Have you lost anyone? 

SOME SIMPLE PHILOSOPHY 

To stay healthy in mind and body, we all have to try to avoid the stresses related to expected and unexpected changes–even those as basic and expected as the change of seasons.  Jane McKeon, of Better Homes and Gardens, wrote in one of her gardening articlesWISDOM: Frost reminds us that we’re not in charge after all.  How do we let go? Laugh at our failures, but don’t repeat them…Observe. Learn. Let go.

On one level, Jane is talking about gardening, but on another her words mean much more. We all experience life changes that affect our physical and spiritual health. Sometimes we are happy for these changes, other times we pray that they never happened or that they will end. In the latter case, we might clench our teeth, tense up our body muscles, even lash out at those around us, the people we love. Or…we can let go. It’s challenging, but there are times that call for  examining or admitting our struggles and our failures, discovering what might have contributed to them, trying not to repeat them. Bottom line, we are allowing a change in our own personal seasons. 

FINAL THOUGHTS 

There will be frost—for we are not in charge. But we can live happier, better lives if we find something about change that strengthens us. A broken bone, a pulled tendon, painful and inconvenient, is not life threatening. It can create a lasting appreciation for that body part, and for the people who do the littlest thing to help us weather that cycle.

On a different note, it’s totally challenging to find anything good in a job loss. That’s a change that requires strength, positive thinking, the belief that attitude is everything. That kind of stress can hurt family relations, ruin a person’s health. In times of struggle, we have to let go, accept the help of others while we are doing everything we can to help ourselves: observing, learning, planting those new seeds. Then we will weather such a season–have hope for new growth; it’s a process we perfect one day, one week, one year at a time. 

Jane McKeon may have intended her words just for gardening, but they are words of true wisdom. For spiritual and physical health, it’s best to accept the flow of the seasons in life, to weather the springs and the autumns. Then you’ll be ready for the winters when they come. Because after frost and snow, spring always returns.

When Will All the Leaves Fall   Primitive art by Debbie Criswell

Relax, Let Go, There's Goodness...

Thoughts on Where We Are…Autumn

Thoughts on Where We Are...Autumn

Autumn is approaching…with winds and light rains, leaves beginning to fall, crops being harvested, trees becoming barren. Ah, the cycle. These weather patterns contrast with the drought and dryness in other parts of America and the world.  What does nature know that we do not about the length of our days? Why do some regions have bounty and others experience loss? Is there something we need to atone for?

Probably. But though despite the shadow fo global warming, I’m determined to enjoy autumn once again. I have a large planter of yellow and burnt ocher mums nestling by pumpkins on my front porch. My autumn welcome sign is hung and a wreath of yellow leaves blazes in in my living room. This is my time. For me autumn is always a beginning.

A CLEARER PICTURE 

When things fall back toward the earth, the outlines of garden and lawn, of walkway and road become more apparent. This precise definition creates a sense of order and organization. In fall there are memories of wild vines and riotous summer flower color. But now it’s best to be more satisfied with quieter denser things like clipped boxwood and evergreens, like bare tree trunks of grey and soft brown. The air is cool. The skies seem swept up too, presenting swathes of crystal color. Cold air outlines things so definitely, you can almost see each leaf and branch.

ORDER BRINGS TIME FOR CONTEMPLATION 

Definition and order soothes the soul. I lean toward putting things away in their proper place. I lean toward knowing that everything sleeps quietly waiting for a reawakening. This is a time to store energy, to store knowledge. It can be a time to read great books and contemplate, make decisions.

If you seek solace and quiet, this is your time. For as we move inside to do our living, placing things we love like a bright pumpkin or a sheaf of leaves on table surfaces, or brightening a room with a flowered pillow or candlelight, it can also become a time to move inward in our thinking–to meditate and determine more and more exactly who we are.

Autumn decorations can remind us of endings, yet good endings that are resolute and leave us feeling blessed, not sorrowful. Autumn is the time of atonement for the Jewish people and how appropriate to tidy up one’s soul as the earth is preparing for sleep and hibernation, as winter winds are soon to come and humans are stocking up on food energy and light energy, hoping they will provide the ability to survive.

ATONEMENT

But no matter what the season, we should atone for the hurts we have caused; we should try to mediate our expressions of anger. And certainly if we have hurt someone we need to ask for forgiveness, hoping that if someone has hurt us, we can find a way to forgive that person, lighten the loads we often carry. And of course, we must try to forgive ourselves.

SETTLING IN 

It’s a little early, but there will come a time as the days get shorter that we will want to settle back into our brains and examine who we are, where we are going, and how we might improve. Life cannot be lived like the riot of spring where nature blows her wad and lets everything grow and rush about. We enjoyed that fertility. But now it’s time to be more judicious in our use of harvest fruits; we need to carefully use and share our bounty.

Certainly in the spring, when life comes back, we have no fears of the future. But in the autumn, we need to count the jars in the cellar, the apples in the basket, the sins on the soul. We need to tidy our lives and draw within to discover how we will survive, how we will make it through the dark times of our life. And how we can help others through their darker, harder times.

FINAL THOUGHT 

In each of us is a light deep within. Sharing that light draws bounty, brings good things to us whether the world is hard-packed snow or dry desert. Autumn can provide a time for atonement. Winter and beyond can be full of the light of love as the grace of forgiving someone brings the warmth of reclaiming love. If you are feeling like all the days of your life are hard, cold winter, then it’s time to open up to those around you, to share the light within you. IT WILL BRING YOU HAPPINESS. As a wise woman once said to me: “Feeling sad today? Then go out and help someone else.” She was so right.

(this is a rewriting of an older post, but it always feels just right…)

Mom Lessons: How to Lead a Good Life

Mom Lessons: How to Lead a Good Life

When my mother would gaze out at the late afternoon light, the golden afternoon she often called it, (a reference to a song lyric), she often become sad. “Why?” I once asked, and she explained that she would see the fathers coming home to their families, and those moments in the day, more than any of the others, reminded her–she was doing this all alone.

My mother was widowed at the age of 34, my father dying too young, leaving her with three children under the age of six, and the possibility that she would pull into herself, wish for a vastly different situation and let sorrow and anger fuel her life.

She did not. My mother taught us responsibility, loyalty. 

Her complete love for us became her focus, her sadness more and more remote. With creativity and love, she took on every challenge, big and small. When I look back on how she raised us, loved us—there was no better role model, ever. My mother became one of the first working mothers in our neighborhood, and like everything she did, she excelled.   

She taught us the rewards of a consistent, well-organized routine—today we would say she was multi-tasking.

To pay the mortgage and feed us, she worked at home, typing insurance policies in our dining room. At night, after dinner, she did what she called “processing” of the work she had completed during the day. She would sit at a card table in our living room, pull the copies she had typed apart, sort them into neat piles. This required paper clips, staplers, pens, glue and often her signature. While doing this, she could monitor our television watching, help us with our homework, even comment on the books we were reading.

My mother taught us that all you really need for entertainment is books, art and music.

As we grew, our living room vibrated with classical music, jazz, opera, musical comedies, The Beatles, The Beach Boys…my mother encouraging my older brother to read the Schwann catalogue and order recordings from the local record store; (in college he had his own classical music program on the university’s radio station); she encouraged my younger brother to learn how to play the guitar; (after college he moved to LA and within a year was on his way to a career in recording and promoting pop and contemporary music.)   

From the moment we all could sit still, my mother read to us, shared storybooks, later colorful art books with glossy photos. When we learned to read, there were weekly trips to the library where we checked out stacks of books, my mother modeling the importance of reading for knowledge as well as enjoyment.

And there were chores. Each of us had an assignment to keep our home clean and efficient. We made up songs, created lyrics to get through doing the dishes, though sometimes those lyrics were created to tease our youngest brother. We got in trouble for it.

Our mother taught us that when feeling sad, you might try singing.

Our mother had a beautiful voice and whenever we traveled she would sing while she drove–another way for us to learn popular music and how it just made you feel good. Crayons, paper and water colors were always available in our home to encourage creativity and to celebrate birthdays, holidays or just to say thank you.   Mom loved receiving the tree and house drawing that were my staple–and the I LOVE YOU message with X’s and O’s.

Our mother taught us responsibility, and that it was wise to save money. 

All of our lives, we were witnesses to good mothering—our mother, grandmother and our wonderful aunts. They challenged us, helped us look to our futures so that we might learn to dig in, contribute to the pace and satisfaction of our shared lives. We put up storm windows, mowed the lawn, raked leaves and planted a garden. I always cleaned the house. There were days when we fell back into kid-like behavior and Mom wasn’t all that happy: found us laughing at cartoons on a Saturday morning (two of us in college) while she came stomping up the back steps loaded with groceries. She got over it. She was human too.

Our mother was frugal, always driving used cars and buying her clothes on sale. She saved money for those things that brought true meaning into our lives. Thus we had a piano, and eventually a good turntable and speakers, as well as hundreds of books and framed watercolors on our walls.

Mom, through her example, taught us how to be kind and generous.

We learned that acceptance leads to happiness, contentment, though our mother certainly felt anger and disbelief when my father died suddenly, when she had to realize that she could make her life about us, about helping anyone else who was experiencing sorrow. She replaced her sorrow with gratitude, and whenever a friend or acquaintance was ill or had died, my mother was there to provide comfort. Our mother could give—but she could also receive.

Our mother taught use to accept gifts graciously. 

The doorbell would ring and there was Gen and her daughter with a box of hand-me-down clothing for me. There was also a friend who actually worked in a toy store and once a year he’d arrive with very expensive toys in three huge boxes—one for each of us. We were thrilled.

When you accept the generosity of others, the upside is giving back. Mom always had a bag or box or envelope for the people who cleaned for us or did repairs. Thank you were two words often heard in our home. We took them with us, bestowing them on others throughout our lives.

Other gifts…

Our mother inspired our desire to travel, to experience the world. She took us on a train trip from Chicago to California. She drove us to Washington DC and back, widening our vision and future goals. She sang as she drove, love songs reminiscent of my father’s courtship days—The Man I Love, Someone to Watch Over Me, Night and Day. I watched the land flow and listened to her beautiful voice, realizing that the songs brought back comfort and the powerful memories she cherished. I will always be grateful she shared them with us.

Our mother’s gift of freedom….

Our mother never married again. When she wasn’t busy caring for us and then for her grandchildren, she continued to work as a secretary in downtown Chicago. She always loved to travel—her last trip flying to Prague in her late eighties. Everyone who knew my mother received a gift from her—a note, a letter of encouragement or a series of prayers said with her worn rosary beads. Mom’s gifts were endless and enduring and I was gifted when she allowed me to hold her weary hands as she took her last breath.

Her final gift: she taught us that we could go on living without her.

 

A Woman’s Biology: Risk and Guilt

A Woman’s Biology: Risk and Guilt

Because of their ability to conceive a child, give birth, perpetuate the species, women have for centuries been honored, sometimes considered saintly, but often buried too soon to live a full and creative life. But precisely because of this biological endowment, this ability to help perpetuate the species, women have also been treated cruelly, taken for granted, sometimes considered evil witches with powers that require control and abuse.

As a former Labor and Delivery nurse, I was fascinated by a recent article that appeared in the New York Times. It’s a personal recounting by writer Leslie Jamison of her C-Section experience, and the research she did concerning this medical procedure. (Posting this after the unethical decisions being made in Texas, only underlines the importance of healthcare for women in any situation related to their reproductive rights.)

JAMISON, A PERSONAL HISTORY  

Jamison starts her piece by recalling the words she used to discuss the birth of her daughter. “When they got her out…”

Jamison writes: “…the day after my daughter’s birth, I found myself emphasizing how much I held her, how I never wanted to put her down. It was as if I felt the need to compensate narratively for that first hour, when I wasn’t able to hold her at all—to insist that we bonded just as much anyway. I found myself exaggerating the part about the not caring if I was numb before they cut me open, when in fact I did care. I told the doctors that I would actually love some more anesthesia in my epidural…as if I were trying to make up for other kinds of pain I didn’t experience – unwittingly obeying the cultural script that insisted on suffering and sacrifice as the primary measure of maternal love.”

Jamison states that even now, 3 years later, when women describe pushing out their babies or having 40 hours of labor, she feels a pang of guilt, a kind of shame, as if her own birth story “wasn’t one that merited pride or celebration, but was instead a kind of blemish, a beginning from which my daughter and I must recover.” She then provides a fascinating history of the Caesarian section. A few excerpts: French obstetrician Jean Louis Baudelocque wrote: “That operation is called Caesarean by which any way is opened for the child other than that destined for it bye nature.”

JULIUS CAESAR–AH, THAT’S WHERE WE GET THE NAME? 

There is an apocryphal story that Julius Caesar was born by cesarean, as his mother survived the birth and went on to bear more children—at a time when it was impossible to survive a C-section. She tells us that in 1925 Herbert Spencer, a professor of obstetrics at the University College London, speculates that it “was called Caesarean as being too grand to have been first performed on ordinary mortals.” He also calls it: “the greatest of all operations, in that it affects two lives.”

But Jamison knows and we know, that for most of history, the procedure saved only one life. The mother did not routinely survive, until the 20th century, because before then, the procedure was usually deployed as a last-ditch effort to save the child, the mother dying, bleeding out, or already dead.

MACBETH, A FORETELLING  

Historically and in literature, the C-section was often associated with the imperial, with the divinity. In Shakespeare’s Macbeth, the cesarean-born Macduff experiences a birth that is an answer to a riddle: The witches have promised “that none of women born shall harm Macbeth” but in Shakespeare’s creativity, Macduff is exempt from such a foretelling as he “was from his mother’s womb untimely ripped.”

Jamison, a modern woman looking back on the history of a procedure she has experienced, makes the comment that Macduff’s exceptional birth might grant him some singular power, but such a birth also relates monstrosity. “Untimely ripped doesn’t exactly summon the epidural and the blue tarp.” Jamison knows, she’s been there.

COLONIAL AMERICA 

Of course, the early history of the Caesarean, a little used and experimental procedure, did not insure life for either the infant or the mother. But neither did natural childbirth. The baby was often fortunate if he or she survived. But in the graveyards of Boston and other parts of the New England states, where our early settlers are buried, you can often find a series of graves for a family. First is the grave of the husband, his dates, which always extend his time of life. Then alongside him are his wives—sometimes two or three. No, he wasn’t a bigamist, but when the first wife died in childbirth or from puerperal fever (see below), he married again, and if that wife died, he married again—eventually not for sex or more children, but for someone to raise his progeny, feed and clothe them, tend his garden.

THE SHAME FACTOR 

Jamison also discusses how the advent of the C-section has been used by some to shame mothers. In his book, Childbirth Without Fear, Grantly Dick-Reed inferred that pain during delivery was a lesson women needed to learn. “Children will always mean hard work and will always demand self-control.” Easy for him to say when he’s standing by the delivery table and not lying on it. 

FINAL THOUGHTS  

Jamison’s article is pivotal and for her, she worked through the angst of her fears and regrets. But the end of the article speaks truth for all mothers, no matter how we have brought our children into this world. Jamison writes: Why do we want so much from our birth stories? It’s tempting to understand life in terms of pivotal moments, when it is actually composed of ongoing processes:not the single day of birth but the daily care that follows…diapers and midnight crying, playground tears and homework, tantrums…If we are lucky, birth is just the beginning. The labor isn’t done. It’s has only just begun. 

For more information on Puerperal fever that caused the deaths of post-partum women, go here https://boomerhighway.org/living-in-the-body-part-2/

Bridget Reyes / A Little Muse Photography

Medical Dramas: They Can Educate

Medical Dramas: They Can Educate

I like reading and sharing pieces I find in the NYTimes, Chicago Tribune, WSJ. THIS IS ONE OF THEM… the title of the piece:

IN A TV SCRIPT, I CAN REWRITE A PATIENT’S FATE  by Daniela J. Lamas  

Dr. Lamas is a writer and co-producer for the television medical drama, The Resident, though her main employment is that of a pulmonary and critical care physician at Brigham Women’s Hospital in Boston. 

MEDICAL DRAMAS AND REALITY 

In her piece in the NYT, Dr. Daniela J. Lamas is very aware that she straddles two worlds, finding the writing gig an uplift from the death and dying she sees in her hospital’s Covid unit. When she can retreat to her messy call room, she uses Zoom to join a group of writers struggling with a scene, another medical emergency for Conrad Hawkins (Matt Czurchry), the eponymous hero of the The Resident.

Lamas never works in a vacuum, taking with her the image of the older female patient who now has Covid, her pastor having insisted she not get the vaccine. Dr. Lamas presents this situation to her writing team, hoping they will change the story line. Example: the pastor visits, sees his parishioner suffering and begins to preach from the pulpit that all his people need to get vaccinated. (But like Dr. Lamas, this story line is my creation. Will the writers group accept it?)

Dr. Lamas writes her reality: …though her lungs are slowly improving, her kidneys are worsening, and she is profoundly delirious, not waking up. We stand at the bedside and call her name, her eyelids flutter.

Down the hall, we titrate drips and manage vent settings for a man whose stem cell transplant cured his leukemia but ravaged the rest of his organs. His wife would be at his bedside, but she is at her father’s funeral.

And though the article does not say, I imagine this elderly woman did die from Covid, an unnecessary death.

STORY LINES THE WRITER’S ROOM REJECTS

Dr. Lamas writes: I used to want to show the hospital as it truly exists, to reveal the humor and tragedy and grace that characterizes my world. (She explains with the following examples.)

  • The family that came to say goodbye to a dying woman, a misplaced ID card leading them to believe, wrongly, that she was their mother.
  • A patient’s brother, with skull tattoos on his shaved head, who told us he could not be in the room when we took his brother off the ventilator. So when he left, we thought we would never see him again, but were surprised when he returned, not to sit by his dead brother, but to collect the man’s prosthetic leg. Another nurse said he spent the rest of the day in the hospital chapel with the leg beside him.

Dr. Lamas writes that even producers and writers for The Resident say such stories are simply too grim. The public does not need or want to be reminded of how quickly things can go bad, how families fall apart, how doctors do their best but patients still die.

Especially now, viewers want to see their doctor as heroes, to follow a formula that has doctors saving lives more than losing them.

IN THE WORLD OF THE TV HOSPITAL

Dr. Lamas writes: “During my first experience on the set…I learned that when things went wrong (a medical word being mispronounced) I was assured, “Don’t worry. We can fix it in post.” She underlines that she loved that phrase, one she wanted to say to her patients over and over. “…to be able to have another chance, to treat the sepsis earlier, to stop the pastor form advising against vaccination, to fix it in the post.”

Dr. Lamas reminds us that during the pandemic, her roles as a critical care doctor and a television writer are often in conflict. Though she wants to honor and remember every patient who died, she also yearns to tell stories that are hopeful, where there is always the chance for recovery, no matter how dire the diagnosis.

“It’s a tension I am still learning to navigate. How do we tell stories that feel true while also keeping viewers engaged? What kind of cheats are acceptable, and which are irresponsible?”

Dr. Lamas then makes a particular reference to the struggle that often ensues when the team is trying to save a cardiac patient. She reminds us that TV characters survive cardiac arrests far more often than people in real life do.

“…and the nurse left alone to clean up after the death…” If our viewers could see that, “they would change the channel.” She is right. I still remember during my Cardiac rotation, watching a team try to save a patient, the family waiting in an adjoining room. The man died. And yes, the floor was littered with medical pads, bottles, wipes, tubing…

IN THE REAL WORLD

Dr. Lamas is right when she stresses that medical dramas are important, that they can provide escape, but also education.

“In the writer’s room, we have a change to …offer a different ending to the story. And in doing so, we can sneak in potentially lifesaving education—early warning signs of certain illnesses, the dangers of overtreatment or the impact of inequities in access to care…television dramas have an unparalleled opportunity to educate and even to change behavior…I have come to believe that it is worth glossing over the facts IF we can weave a story that encourages viewers to trust science, to get vaccinated, to look differently at disease. When I find myself fact-checking what I see on the television monitors, I remind myself of this more important goal.”

Dr. Lamas ends her piece, mentioning a patient that she met one morning on rounds, asking him to mute the TV show he was watching, a medical TV show, as she needed to listen to his heart. He seemed surprised that he had to miss something, explained that medical dramas had been his one constant. The plots reassured him, taught him what might be ahead in his own medical story, while helping him feel less alone on his own medical journey. Dr. Lamas smiled. She understood.

(I confess that one of the reasons I became a nurse after having my three children—was my propensity to be gripped not only by books and articles about medicine, but by watching television medical dramas. I’ve written about that before. I was an avid ER fan. Now it’s New Amsterdam, Chicago Med, and of course The Resident.)

A Gardener’s Beginnings: Another Chapter In My Story

A Gardener's Beginnings: Another Chapter In My Story

Some gardeners would say that a most enduring gift to offer a loved one would be a bouquet of blooms from their own patch of earth–red roses for passion, lilies for purity of heart, or some new cultivar that amazes with its scent and beauty.

But I say: what about dandelions? What about those crumpled bouquets of stringy stems and crushed flower? They are fervent, perfumed with a child’s love and devotion. They stretch across the years, becoming an eternal gift. But they could also be a gardener’s beginnings.

MY STORY

For me, it was the peony, those perfumed beauties bursting out in spring, to be picked and brought to my mother, who, to support her three children, because my father died early on, was typing insurance policies in our dining room.

Sometimes, she would take a break, and together we would sit on the front porch steps, drinking in the beauty of the eight bushes that lined our front walk. Spring was the perfume, the color–fuchsia, rose, white, their large yellow centers, truly cabbages of color that became pendulous in spring rains, heads drooping like my head on my mother’s shoulder. The best part? Getting a scissors and bringing them inside to fill jelly glasses, transforming our simple home with their color and scent.

BUT THIS, MY FIRST GARDEN

It happened when I was ten. My two generous aunts had this everlasting garden with stepping stones! They talked a language of bearded iris, delphinium, coreopsis, and rose scale. At our house, I watched the green grass turn brown, the bridal wreath bloom off, leaving only ragged masses of dusty leaves, while whiz, bang, I could hear my mother’s typewriter through the open, summer window.

But my mother listened to me, and with some money from her budget, we bought marigolds and petunias. She showed me how to plant them in a patch of soil by our gravel driveway–my first garden! She found time to help me pot some scarlet geraniums for the front porch, and she showed me how to hook up the sprinkler and water the lawn. IT WAS A START!

Then, as summer faded, magic happened. I gave her a bouquet of spicy marigolds, which we carefully arranged in my grandmother’s cut glass powder dish. (See the photo above, as I have recreated this moment.) A lovely present, but not as lovely as the look in her eyes when I presented them.

I WAS A GARDENER NOW…

I was like my generous aunts who came up the front walk on a chilly night heralding the arrival of autumn, bearing sheaves of chrysanthemums expertly cut and wrapped in waxed paper to protect their well-ironed dresses. Mom and I exclaimed over the amber ones, the maroon ones, the bright, fiery yellow ones. My brothers moaned. Autumn to them was heavy storm windows that had to be hung, the window washing that went with that chore, and expanses of leaf-covered grass.

For me, I was beginning to appreciate this part of a gardener’s cycle–the tidying up, the banking of the peony bushes with dried leaves, the getting ready for winter. It all had a purpose and finality that I didn’t mind–it held a promise.

That first winter, after I became a gardener, I would gaze at the snow-encrusted world, imagining an eventual thaw, the peonies parading the front walk–the re-creation. The spirit of gardening had taken hold of me, and I learned in time that it’s a firm hold, one you give yourself to over and over.

In my youth, the promise lived in the simple gifts I could give my mother. Yes, the flowers sang out to us, called to us with their colors and perfume, solidifying even more our love, now cultivated by our very living.

A HOUSE FULL OF WINDSORS

A HOUSE FULL OF WINDSORSSometimes you come across a novel that reminds you of your own personal proclivity (and to better explain: a tendency to choose or do something regularly; an inclination or predisposition toward a particular thing.)

Those who regularly read my posts, know that I am quirky in some ways, one of them being that I have an interest (a slight passion?) about all THINGS BRITISH. But especially the Royal Family, the Windsors.

And most of you know that this started because of my name, which led me to read British history as if I were preparing for a Master’s Thesis, all while being encouraged by close family members who visited England and brought me memorabilia; all while discovering it was meaningful to cut articles about the Windsors out of newspaper, or save magazines with photographs, ask for books about their lives and watch royal weddings on TV.

My family didn’t mind too much, because if they questioned me on this rather strange proclivity, I could always say it’s just another way of learning more about HISTORY. 

But then, along came…

A FELLOW ANGLOPHILE  

Because the Internet connects you to people you would otherwise never meet, and thus connected me to Kristin Contino, who when it comes to this particular proclivity, this love of the family of Windsor, certainly has me beat.

Kristin’s many trips to England have been recorded with numerous photos. And when a major royal event was about to take place, she and her family once again made the trip, finding a spot near Windsor Castle and able to be up close and personal observing the pageantry of the marriage of Prince Harry and Meghan Markle. After that, I knew I’d found an even more ardent follower of the Windsors…but that event was only the beginning….

Kristin has a reproduction of a bright red British Phone Booth in her home, not to mention those items which all of us seek out when celebrating the royals: tea towels for weddings; tea cups and plates; photos and books. I have a few. (See some of mine below.) Kristin? She’s the QUEEN OF COLLECTIONS. 

And then the final example of her passion, the arrival of Contino’s novel: A HOUSE FULL OF WINDSOR, a delightful story whose main character, Debbie Windsor, falls in love with a member of the landed gentry, Alan Percy—and whether it’s being enthrall to London or Buckingham Palace or her love for Princess Diana and everything royal, Debbie collapses into the arms of this tinged with royalty but not so gentle man—and bloody hell, she gets pregnant. First with Sarah and soon after, with twins!

But later, we find her back in the good old US of A, her marriage over, yet her desire still for all things royal filling up her house. Debbie has become a hoarder. She lives in a house full of windsor. And because she now has trouble navigating her rooms because of the overflowing bins of British mementoes, her three children know that SOMETHING MUST BE DONE.

Will Debbie find a pathway through her living room? Will Sarah, who provides the reader throughout the novel with her Sarah Says tips, have the answer? Maybe so, as her first TIP encourages readers to be ready for company, but then immediately acknowledges that in her family, “dirty secrets are best swept under the rug.”

I’m sure Kristin Contino had fun writing this book. Her photos of her trips to England, her love of those red telephone booths are testament to that. The novel is light-hearted and from page one presages a happy ending. Her characters make predictable decisions so that everyone is jolly and red-cheeked with happiness in the end. And the novel is clever, the hoarding is real, because when you’ve fallen in love with the photos of the Windsors and Princess Diana, it’s understandable that you might go for cheeky Alan, that rotter, who chases birds (that’s British slang for girls)—but in the end decides that bloody hell, you better let your children help you out so that life is cracking again.

A HOUSE FULL OF WINDSORS

 

Memories and Their Power

Ann Patchett says: I’m very sure that my memories are true and accurate, and if I put them up against the memories of my family or my friends, they would have very different true and accurate memories. Even if they differ from a sibling etc.

Salvador Dali, The Persistence of Memory

“You have your wonderful memories,” people said later, as if memories were solace. Memories are not. Memories are by definition of times past, things gone. Memories are the …faded and cracked photographs, the invitations to the weddings of the people who are no longer married, the mass cards from the funerals of the people whose faces you no longer remember. Memories are what you no longer want to remember.”
Joan Didion, Blue Nights

That’s Joan Didion, her words veering toward the negative. Because loss is tragic, hard, challenging. She longs for her daughter. That loss shakes up the foundations she depended on, and I applaud her words as a search for strength.

But can we be nostalgic when we are young? Yes.

Anne Frank was, writing in her diary of days past, knowing those days were gone, that her world was imploding and that she might never again sit in a classroom, walk the streets of Amsterdam free and unhindered, look forward to love, marriage and children.

Anyone who looks back in longing–for a friend, a house, a parent, an experience, can feel and write about their longings–this is nostalgia. You want something back, that you don’t want to forget.

CREATIVITY AND REMEMBERING 

There was a time when I began to write, that nostalgia seemed to propel me. Why? I was young, and I saw that my experience was in some ways limited. Some changes in my life had already happened (loss of a parent, early responsibilities as a result). And I saw that I didn’t want to relive my childhood, but that it dwelled within me, making my losses and gains part of me, the engine of my creativity.

Because when you write, you are either pulling things out of your own experience or making shit up. Both land on the page, and wow, you’re a writer. (Though not necessarily a good one. It takes time, lots of time. Maybe forever.)

SO WHAT IS THE ENGINE OF CREATIVITY?  

When Author Ann Patchett (Bel Canto, The Dutch House, Commonwealth) takes a memory and infuses it with meaning, she then uses it in one of her novels. She describes her process this way: “I’m very sure that my memories are true and accurate, and if I put them up against the memories of my family or my friends, they would have very different true and accurate memories. Even if they differ…” Because we know that fiction comes from seeds of experience. IT COMES FROM LIFE, FROM LIVING. And what one person sees or hears or feels, can differ from another.

EVEN FICTIONAL CHARACTERS LIVE IN OUR MEMORIES 

One of my favorite authors, Elizabeth Strout, discovered that her characters refused to stay within the pages of past books. Though Strout left her home in Maine for New York City, Maine stayed with her. So did the voice, the face, the life of Olive Kitterridge, the eponymous title of the collection of short stories that won Strout the Pulitzer for fiction.  But Olive wasn’t finished. She continued to speak to Strout, and thus Olive Again came to be, more stories that take us back to Maine, but also (and this is to amazing and clever) bring back characters from Strout’s other novels. It’s delightful for Olive to find herself living in the same senior facility as the mother from Amy and Isabel, that being only one example. After writing My Name Is Lucy Barton, Strout felt compelled to learn more about Lucy’s beginnings and sent her back to a small town in Illinois to reconnect with her siblings and other in a collection of stories, Anything Is Possible. We all do this: let our memories grow, fill out the stories of our lives, enhance them. At some level WE ARE ALL STORY TELLERS. 

WRITE IT DOWN 

Many of us kept or still keep a diary. It’s our lives on paper, our deepest thoughts and even our anger and our hurts. It’s not fiction, but it can fuel fiction and it always comes from the power of memory.

Talk to an old friend. Discover that the mention of a place, a high school crush, a certain teacher brings back a flood of memory. And though they aren’t always positive, they are part of our lives. Joan Didion wrote Blue Nights after losing her daughter. She wrote The Year of Magical Thinking after the death of her husband. Joan used the power of her memory, of her words to seek healing. Each and everyone of us is a vessel of stories. Write them down. They are part of you, and they have power.