Birth and death

Feldman, Perle

It's about Kavannah. Kavannah is a Hebrew word, which is usually translated as "intention", but denotes an intensity and attention to a task, usually prayer, which elevates it from the mundane to the holy. My work as a Family doctor and teacher cries out to be done this way. I try to really hear what the patients are telling me and to truly see what they are showing me but often routine and distraction and the realities of life interfere and it becomes a job. Sometimes, however the truth and beauty in what we do jumps up and slaps me in the face and I feel profoundly connected.

The edges of life are often where holiness is found and I love the hierophantic aspect of my work, helping to guide souls into this world and out of it.

I was working in my clinic where I see most of my pregnant patients. With me was one of the first year residents, a young woman who has already achieved many things. This girl combines a shining intellect and great curiosity, with gentleness and compassion. Also there is my young cousin. I remember when she was fifteen years old and our Family picked her and her Family up at the airport when they emigrated from Russia. The chattering magpie child has grown up into a thoughtful young woman who is a medical student at University of Montreal. She is doing an "observership" with me. This is an unofficial elective to reassure her that clinical medicine is indeed what she wants to do when she grows up.

In for her prenatal visit came Lucette. This is her third baby and I have taken care of her throughout all three pregnancies. The first baby was breech and she had a Caesarian Section. The second Birth was a triumphant VBAC. Her two sons, a pair of sturdy boys, strongly resemble their fireman father. Chris is a gentle bear of a man, a hockey player with a bristling red moustache and a self-depreciating humor. He often looks at Lucette with a bemused adoration as if he cannot believe that he got to marry such a prize.

And a prize she is, poised, smart and elegant, even in the ninth month of pregnancy. She looks like a full rigged yacht with the spinnaker out a she moves gracefully in the cramped confines of the examining room. She radiates competence and self-assurance. She has seen both the Resident and student over the past few weeks. As an ICU nurse, she knows a lot about medical trainees. I am a little surprised but very pleased and gratified when she invites both of them to attend her Birth. The two of them are also pleased and agree to try and come.

The next morning Masha, the student, and I go to visit my elderly patient admitted on the ward. This sweet little old lady was admitted for pain control following multiple spontaneous fractures either secondary to osteoporosis or from myeloma. A week earlier she had suffered a massive heart attack. They had stabilized her in the CCU but her heart was basically hanging by a thread, the pain from the fractures was unremitting despite round the clock morphine. "I can't anymore," She whispers to me in Yiddish, the enormity of her statement making her relapse into her mother tongue. " I need to live until my grandson's Bar Mitzvah on Saturday, then I want to go". My eyes fill with tears and my voice is choked. "I'll try". I say to her, not sure what I am trying to do, keep her alive three more days so that her grandson's Bar Mitzvah is not ruined by her death or arrange somehow for her to die soon after. I review her case with the cardiologist and we make plans. I speak to her two daughters. They are two very different women, not really close in their own relationship but brought together in the bond of their love for their mother. Her husband is reduced to a weeping, childlike state. He does not want to take part in any discussions, leaving all decisions to his daughters. I carefully explain the situation as well as I can understand it. It bothers me that I do not really have a diagnosis for her bone pain. Somehow this whole situation would be easier for me if I knew for sure, that she had myeloma: giving morphine and withholding treatments is easier if one has a diagnosis of cancer. I won't, however put her through the pain and indignity of a Bone Marrow biopsy. Her long time hematologist is even more hesitant than I am. "Let's take care of her, not ourselves," he advises me. Masha is with me during these visits and discussions, often standing at the door, not wishing to impose herself on the grieving Family. I am very aware of her eyes on me; I am trying to do this right.

Three days pass, the Bar Mitzvah happens. The Bar Mitzvah boy comes and sings his portion and gives his speech for his Grandmother in her hospital room. She is very weak, drifting in and out of conciousness. A few days later she is still alive though barely. "It's so hard to die," she whispers to me. Her daughters dissolve in tears.

Friday night, at around 10 p.m., I get a call from the caserooom. Lucette is there and in good labor. I call both Masha and the Resident, they are both keen to come in.

A few hours later I get a call that Lucette is 6 cm dilated, so I rise from my restless sleep and mosey into the hospital. Lucette and Chris are standing next to the bed, tethered by the monitor, which she needs because of her previous section. They are slow dancing their way through labor. Lucette leans heavily on Chris' shoulder moaning softly with each contraction. The Resident and Masha are already there. When I examine Lucette the cervix is 8 cm with bulging membranes. "Are you ready?" I ask Sharon, the resident. Her usual self-assurance is gone she is both eager and anxious, her eyes are shining but her hands are shaking a little. I show her how to break the waters and a clear gush of fluid follows her tentative poke. "It's my first delivery" Sharon whispers to me. "Oh your first!" Lucette has heard her, "you must do it then, you have to do your first delivery with Perle!"

"It's my first delivery too" says Masha; "I've never seen one before". Lucette smiles at me, our eyes lock, we all know our roles here. Lucette and I are joined together; we are the teachers, the priestesses, initiating these two young women into the mysteries of Birth.

A few minutes later Lucette is ready to push. We all form a circle round the bed, Chris and Masha each take a leg, Sharon and I are at the perineum, the nurse standing by, next to the baby bed. Gently, gently working in synchrony Lucette pushes a little red headed girl into the world. My hands gently guide Sharon's through the maneuvers. Masha's mouth and eyes form three perfect circles of astonishment and delight as she witnesses the miraculous emergence of this beautiful child. The room is at first intensely silent and then bursting with joy. Lucette gathers the baby to her breast and Chris is crying. I am so happy. The whole Birth was so smooth, so easy, so focused. I went home and fell into bed.

Two hours later I get called, groggy I lift the phone, my elderly patient has died. I have an unworthy desire to turn over and go back to sleep, but I know that my duty is really to the living. So I haul myself out of bed and drag on my clothes. I go to the hospital, pay my last respects and talk it through with the daughters. The last office of the physician is to walk people through this most difficult of transitions. The daughters and the husband thank me for my care. It is good

I leave, grabbing a coffee in the nursing station, to join my Family at synagogue. I think about how lucky we are as Family doctors to have this opportunity, to have Birth and death so closely linked, to be there at these important moments of peoples' lives.

I enter into the glowing golden light of our little Shul, I see my husband, tall and bearded, looking very Old Testament in his Kippah and prayer shawl. My daughters stand beside him like flowering trees. My son, his face serious, his eyes wide with the responsibility of his up coming Bar Mitzvah is really focusing, not running out to play with his friends as he did such a short time ago. Feeling a little grubby, I slip in between them, and give myself up to the service. I pray with Kavannah.

Theme: Birth | Naissance
Theme: Death and Dying | Décès et le mourir
Theme: Patients | Patients

Stories in Family Medicine | Récits en médecine familiale [Internet] Mississauga ON: College of Family Physicians of Canada. 2008 --.




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