The Assent Of Man

October 12, 2010

This time I had my wallet open, five-dollar bill in my hand before Dana turned to help me.  It didn’t matter.  We danced our usual dance.

“That one’s on the house, honey,” she said, smiling and nodding toward the cup of coffee in front of me.

“No, no,” I said.  “I’m paying,” and put the five on the counter. She pursed her lips, traces of the smile still there, and shook her head.  A lock of thin, blonde hair escaped from her ponytail and slid down past her ear.  It covered part of the tattoo on the side of her neck.  I had forgotten about her tattoo.  Her eyes, blue and a little bit puffy, crinkled in mock anger.  I frowned a little at her for real, as if to say, “Just give me a break this time.”

Usually I dance along, matching her smile for smile and gracious for gracious.  Today I needed a win.  The weather was gray and drippy, I had stayed up too late the night before, and I wanted to get through morning rounds at the hospital quickly.  There was no one in labor — if I were lucky, I’d be able to shave a bit off of the pile of paper on my desk before being paged.  Just let me pay for my coffee, I thought.  I don’t want to talk, I don’t want to play games, I just want to get to work.


The day before in clinic had been busy and frustrating.  I had left notes undone, had put off the filling out of forms.  After clinic I had gone home, fussed at my wife, and nagged my boys until the living room and kitchen were tidy.  Then everyone had escaped to their rooms or their friends’ houses, leaving me alone as I drank wine and folded laundry.

Somehow that hour folding laundry felt like the only real one of the day.  I reveled in the quiet.  I poured the glass of wine, sipped it, plunged my hands into the warm, dry, inchoate mass of cloth, and then piled it on the table behind me.  Sip wine, match socks, sip, smooth and fold pants, snap and fold towel, sip again.  I brought order to chaos.  I felt like a god.

Folding laundry makes me feel like a god.

Being a doctor doesn’t.

Even the infrequent life-and-death moments that I face feel quite earthly.  My work mostly involves the give-and-take negotiations of office visits.  When I’m on call at the hospital, I occasionally face a tense situation (like a difficult birth) that requires calm and focus.  Those moments are less common than you might think.  Lapses and wrong decisions can have terrible consequences, of course, so, like my colleagues, I’ve developed rituals that I follow compulsively.  It’s not exactly a godlike existence.

The paperwork is my one work-related shot at godhood.  Shrinking that pile brings order to chaos.  It doesn’t feel warm and soft in my hands like clean laundry does, but that’s not the problem.  The problem is that the pile is a prank played on me by the real gods.  When the 7PM pile is bigger then the 7AM pile had been, I am Sisyphus.  When it’s smaller, I am Tantalus.

Last night I was Sisyphus.  I’d rather be Tantalus.

Today I could be Tantalus.


Dana didn’t let me off the hook.  She leaned towards me, over the counter, and said quietly, firmly, “This is on the house.  I wouldn’t have my son if it wasn’t for you.”

That was simply not true.  I’ll tell you what really happened.

I first met Dana a couple of years ago.  I happened to be on call the weekend she went into labor.  Her labor was pretty normal — we had a few worrisome moments when the baby’s heart rate dropped, but he turned out to be fine — and the delivery was straightforward.

There were only two reasons why her delivery sticks in my mind.  One was that she had come in determined to give her baby up for adoption, and had asked not to be shown the baby after he was born.  Then, just before she started the pushing phase, she announced that she was going to keep the baby, and would I please please hand him to her when he was out.

After I handed him to her, she clutched him as if he were her long-lost love, but she didn’t kiss him or nuzzle him.  She looked at him with astonishment, as if she weren’t sure he was real.  She barely seemed to notice when I delivered the placenta, or even when I stitched her laceration.  She held his slippery little body tightly to her chest with her eyes closed, then lifted him and stared at his face, then clutched him back again, over and over.  She breathed deep, shaky breaths, and silent tears trickled down the sides of her cheeks.

The second reason I remember her delivery is that she works down the street from the hospital, in the cafe where I often get my morning coffee.  On the day  I admitted her to the hospital, I had vaguely recognized her as the new person behind the counter at the cafe.  In the process of admitting her, I learned some of her most painful secrets.

She was a mess back then.  She had had problems with Oxycontin and alcohol in the past, although she had been clean and sober since before the pregnancy.   We talked about this on the day I admitted her, and I asked why all of her urine drug screens had been positive for marijuana.  She pooh-poohed this, saying “That’s an herb, not a drug.”

She had had Chlamydia twice (one of those times being at the beginning of the pregnancy).  She refused to name the father of her baby, saying only, “He’s an asshole.  I don’t know where he is.  He’d be the world’s shittiest father.”  She had moved back in with her mother — at the age of 31 — after she had found out she was pregnant.  She said that she and her mother got along well enough, and that she liked working at the cafe.  “I never thought I’d like such a boring life,” she said, and then laughed.

As we finished the process of admitting her that day, I said that she seemed to be finding herself.  She said, “Yeah, right,” then snorted.  “I’d still be a shitty mother.  Maybe someday.”

That night, her baby’s heart rate dipped a couple of times, briefly.  I told her that I was a little worried about the baby’s circulation.  She looked surprised and angry.  The heart rate recovered, and then stayed reassuring.  The next time I came in, she said, “My mom wants to know why you’re not doing a c-section.”  They had spoken on the phone.  I explained that the dip in heart rate was the equivalent of his holding his breath for 30 seconds.  Not a problem in itself, just a little red flag that told us that to keep an eye on the baby.  She was silent for a moment, and then said, “Oh.”  Then, “Ok.”  Then her eyebrows buckled and she frowned.  “You sure?  Just because I’m not keeping the baby doesn’t mean I don’t care.  I’d have the c-section, you know.  I know what’s important.”

I told her that I was as sure as I could be that the baby was fine at that moment, that it was perfectly clear that she cared, that I had assumed she wanted to do the right thing, and that we were going to do everything to make sure we ended up with healthy baby and healthy her.  The rest of her labor and delivery went uneventfully – except, of course, for her announcement that she would not be putting him up for adoption.


Ever since then we have struggled over who would pay for my coffee. At first she pushed me not to pay, saying each time, “I’ll cover it.”  I refused to let her pay.  Sometimes before she handed me the cup, she would announce that she was buying my coffee that day, and then ostentatiously put money in the register to cover it.  I would then put extra money in the tip jar, and she would glare at me.

We gradually accomodated each other.  She loved it once when I said that I didn’t feel human until I had my coffee.  She called me “Dr. Human” for a while.  I felt like more of a Dr. Monster, though, letting this person who earned so little money buy me anything.  After a couple of months we each relaxed, and now she often doles out compliments instead of money.  Sometimes she “by accident” gives me a large instead of a medium, and then says, laughing, “You don’t want me to waste the cup, do you?  You’ll be EXTRA human today.”

Usually when I see her I ask about her baby — now toddler.  She always has photos, and always seems excited to show them.  “He’s my love, you know,” she says.  “God really blessed me with this one.”  I murmur appreciation.  It’s a pleasure to see how happy she has become.


Today, I was in no mood for pleasure.  I was surprised that she so brazenly refused to let me pay.  Then, when she said that she wouldn’t have her son if it hadn’t been for me, I realized that she thought I had saved his life.

“No, no,” I said.  I took a deep breath and put my hands on the counter.  She started to say something, but I needed to make her understand what had really happened.  “He would have been FINE.  Have you thought this whole time that I saved his life?  I didn’t need to do ANYTHING for him.  I don’t remember what I said to you, but, REALLY, I was just a bystander, keeping an eye on him.  YOU did all the work.”

She glanced around, making sure no one was in line, and that her coworkers couldn’t hear us.  She leaned over the counter, put her hand on mine to keep me there, and said in a quiet, strong voice, “Oh, I remember what you said.  I remember EXACTLY what you said.  You said he held his breath.  That’s when I knew how scared I was for my little boy.  That’s when my heart started to open.  You told me that you would keep him safe, and that’s when it opened all the way.  I kept my heart closed the whole time I was pregnant, because I shouldn’t have got knocked up, and I knew I had problems, and I was scared of what my mom would think of me ‘cause I knew I couldn’t be as good a mom as her.”  Her voice cracked.  “But you saw through me, you saw that God loves me, and you told me that of course I cared about my little boy.”

She paused for a moment, and a tear dropped from one eye.  I started to respond, but she pressed my hand harder against the counter to hush me.  “God blessed me that night.  I know it was really Him that opened my heart, and that He worked through you.  I thank Him every day.  But He’s way up there, and you’re right here.”  She wiped her eyes with her sleeve and looked straight at me.  “ You are right… ” She gently knocked my hand against the counter as she said it.  “…here.”  She knocked my hand against the counter again, then clasped it.   “I’ve worked really hard to be good.  I don’t swear no more.  I don’t smoke weed.  I can be that good person you saw that night.  You look stressed out.  Let me pay for your cup of human this time.  OK?  Because God loves you, too.”

My heart opened.

I let her give me the coffee, watched as she fished a couple of crumpled dollar bills from her pocket and put them in the register.  I put my five away, and stood there.  She looked up.  Returning to her usual perky tone, she said, “I get you something else?”

“Yeah,” I said.

I asked her to give me a photo of Robbie, her little boy.  She sniffed once, wiped her nose on her sleeve, grinned, then pulled off the little photo taped to the side of the register and handed it to me.  He has her thin blond hair, her wide set eyes and her broad face.  I put his photo in my jacket pocket, and picked up my cup of human.


Posted in Birth Stories

Song of the Day — David Bowie

May 19, 2010

What a silly time to write.  3 in the morning, while on call.   Following two women each of whose labors are slow, each of whose babies are doing fine.  I could nap for half an hour.  Tomorrow I will regret not sleeping more.

Tonight I am fascinated.  And once again Late Night Exuberant Nick indulges himself at the expense of Morning Slow-Moving Grumpy Nick.

Thus it has always been.  Thus it remains.

There’s a reason that Harold and the Purple Crayon kept me so absorbed — Harold understood that no matter when the portal of fascination opens, you must take your purple crayon and dive through it.  Go exploring.  Indulge.  It’s a crime against yourself to do otherwise.

Today I got to be present for an amazing labor and delivery.  A young woman from Guatemala, standing all of four feet, eight inches, having spent all of five months in this country, pushed out her first baby — an eight pound, five ounce boy.  Pretty standard story, so far, to my eyes.  We get a lot of Guatemalan Harolds here, keeping their heads down and working their purple crayons to draw new lives for themselves.

What was unusual was her two older sisters.  They were utterly acculturated, speaking perfect English with only slight accents.  Though they were in their mid- to late-20s, they had a total of only one child between them.  They were almost as small and thin as my patient, and worked constantly.  One would murmur in her ear during contractions while the other refreshed the damp cloth and wiped her forehead.  One would draw the bath while the other calmly and forcefully reminded the patient that she was going to do this, that she should breathe through this contraction.  The patient took a few baths.  Each time, when I walked in the room afterwards, the fronts of her sisters’ shirts and jeans were soaked.

After a while, I decided that these women must have attended many births.  I knew that their mother (whose body had borne 9 children) was a midwife.  Not only were these two sisters engaged throughout, nurturing her, coaxing her, reminding her that she was strong enough to get through this, they also had a mastery of the small touches.  The face cloth.  The back massage.  The well timed joke.  It was no surprise, when the disc that monitored her baby’s heartbeat slipped off, that one of her sisters absent-mindedly picked it up, swabbed more gel on it, and replaced it.  Perfectly.  Found the heartbeat immediately.

The aftermath of a normal, healthy birth is always a warm, euphoric scene — a similar feeling to that of a dressing room after a successful performance.  It’s always satisfying to catch the new mom’s attention and explain to her exactly what she, personally, here, today, did that was amazing, and why that means she is likely to be a great mom.  I never lie.  I never have to.  Maybe three or four times I have felt like I couldn’t find meaningful praise, and those times have skipped this spiel and just said congratulations.

Today, I got to do this, and then lingered longer than usual to praise her sisters.  That’s when I found out that, though the eldest had been through her own labor, neither of them had ever attended a birth before.  I must have looked surprised, because the younger of the two then launched into the story of how they had talked to everyone they knew, and had taken books out of the library and watched “many many videos.”  Clearly, this was the project of the entire few months since they had found out about their newly-arrived sister’s pregnancy.

I said, “Excuse me, but we read a lot in medical school, too.  You’re not supposed to be this good at it without experience.”

She laughed briefly, to show me that she got the joke.  Then said, “but it was FASCINATING!”

It is.


One last thing.  Roll your eyes if you want to.  Yes, I’m talking to YOU, my dear.

I want these people in my country.  I’m talking about people who grab their purple crayons, who bust their butts to make good lives.  This is not at all about lefty-liberal politics.  This is me wanting to surround myself with people who work hard and show initiative.  I love that.

You can unroll your eyes now.

Song of the Day — Rimsky-Korsakov

April 28, 2010

I used to wonder how Scheherazade found 1001 stories to tell.  I used to think she could only do so because she herself was a fictional character.  But sometimes I have felt like a fictional character in my own life, and those were the times when I had the fewest stories to tell.  My friend Kenny used to tell me when we were in college together, “Nick, you seem like an actor playing a part sometimes.  And not just that — you’re a LOUSY ACTOR.”

Lousy actors create impoverished stories.

I can act now, some.  Doctor Nick is a role I enjoy, because he pulls so much from my real life.  Writer Nick is the role I rehearse these days.  I can create a richer story than I used to.  I can also chat at parties.  Speak in front of a class of grad students, like I did last week.  Talk sports, as if I were a real guy.

But mostly my life is real, and this real life stuff makes storywriting easy.  It creates stories for me!  In profusion.  Way more than 1001.  All I have to do is pay attention.

Today, for instance — no, how about just the end of my workday?  Shall I tell you what happened with a can of liquid nitrogen, a syringe full of anesthetic, a scalpel, and a patient of mine who wanted a skin tag removed from a very personal place yet could not hold still because she kept giggling?  How I forgot to take my phone out of my pocket, and how it rang at the exact wrong time?  How we made it through successfully despite all that, only to find that the bandaid I had brought was a child’s bandaid with soccer balls on it?  Which, as I tried to decide whether to leave and get a normal one, she grabbed from my hand and put on herself, proudly announcing, “Now I have balls too!”  And cracked up.  As did I.

Shall I tell you this story?


Here.  Listen to the second movement of Rimsky-Korsakov’s Scheherazade, instead.  I could listen to Scheherazade’s theme (is what the solo violin plays at the beginning here) forever.  You can imagine the details of the story while you listen to the music if you want.  Scheherazade’s theme.  Awkward social situation.  The Prince’s theme.  Phone rings.  The Prince and Scheherazade meet.  Soccer ball bandaid.  Take it away, Herbert von Karajan:

Rimsky-Korsakov_ Scheherazade, Op. 35 – 2. The Story Of The Calendar Prince

The Times They Are A Endin’

April 25, 2010

I was a bad doctor the other day, and God noticed.

I mean it.  I’m as secular as the next guy (as long as the next guy doesn’t happen to be Christopher Hitchens).  The only reason I call myself an agnostic instead of an atheist is that atheism requires a level of certainly that I can only imagine coming from scripture, or some other divinely revealed source.  Which would perhaps undermine the idea that God does not exist.

My agnosticism is anything but a squishy position.  It is the only framework that fits with MY core belief, which is that I cannot know anything for certain, and must constantly fumble around with successive approximations of the truth.  (Actually, I don’t believe in truth either, or reality, but that would take us on a second order digression.  Which would be undisciplined of me and unfair to you, because you probably want me to get back to being a bad doctor.  Fine.  Let’s just say that life goes more smoothly when I pretend that reality is real.)

One of the countless things that is difficult to know for certain is whether an episode of acute conjunctivitis is caused by a bacterial or a viral infection (or sometimes whether it is an infection at all).  Any primary care provider — particularly those of us who see children — confronts this problem regularly.  When one’s child is sent home from school because her eyes glow a satanic shade of red, it is an understandable response to bring her to the doctor.

Most often the infection is viral — a cold bug gone astray, a runny nose of the eyes.  If both eyes are affected equally, if there is little to no production of eye boogers (sorry, proteinaceous debris), if the child has a concurrent runny nose, if there is not much redness or swelling around the eye(s), then my response is clear.  “This is a virus,” I say, confidently.  (See!  I CAN pretend that objective reality both exists and is definitively knowable!)  “Wash your hands constantly, keep her home until X and such a time, and call me if she develops these other symptoms or does not improve within a week.”  Then I wash MY hands compulsively and move on.

Usually this involves a discussion with the parent.  “Why is my child not being treated?”  Reasonable question.  We have no antibiotics that help with cold viruses.  “How can you be sure she does not need antibiotics?”  Another reasonable question.  I point out what I see.  Often, we talk about when she can return to school, and the parent stresses about missing time from work.  Sometimes the school has sent a note via the parent saying the child cannot return until treated with antibiotics.  This used to drive me berserk, because sometimes that is just the wrong thing to do.

Often, I prescribe a “backup” prescription for antibiotic drops or ointment.  This is actually a valid approach, because having a viral conjunctivitis puts you at risk for developing a superimposed bacterial infection, which SHOULD be treated.  However, it is also one way to deal with a parent who is convinced that the child needs antibiotics, and who often will continue bringing the child to see other doctors until the child receives “treatment.”

None of which helped me avoid God’s attention.

This past Tuesday*, Luisa brought her daughter Annabella to see me about an eye infection.  Luisa is one of my more frustrating patients.  She always comes with a range of concerns, some of them important to address because they are potentially critical to her health.  She speaks extremely slowly and constantly backtracks and revises, gets lost, then remembers her point just as I am on the verge of despair.   She then often completely rejects the tests I think are crucial for her health, and demands others that are completely uncalled for.

I girded myself when I saw Annabella’s name on my schedule.  Noted the chief complaint of “eye infection.”  Darted in, took control of the conversation immediately and didn’t let go.  Annabella had conjunctivitis.  Fairly classic viral conjunctivitis.  A little worse on the left, a little more boogery and inflamed on that side than you usually see in a viral infection, but the right thing to do would have been to have the conversation with her mother and send her out with at most a backup prescription.

Instead, I thought about my schedule, this visit pinched between double bookings and complicated diagnoses.  I thought about Luisa, and how hard it is to talk to her about important things, let alone this self-limiting infection.  I thought about erythromycin ophthalmic ointment, and how benign it is.

And caved.  To myself.

I walked out of the room, printed a prescription for the ointment, came back in and handed it to Luisa, reviewing the standard precautions and caveats.

“Thank you, doctor,” she said.

“You’re welcome,” I mumbled.  My little seed of shame floated in a warm bath of relief, and I decided that this was an acceptable lapse that would help me avoid burning out before the end of the day.  I turned to walk out of the room.

“Oh, doctor — one more thing,” Luisa said.  (This, in medicine, is called the [hand on the] Doorknob moment, the moment after the visit is over when the patient says, “I have a lump on my breast.  Can you just check it quickly?” or “I forgot to mention my crushing substernal chest pain that started 2 hours ago and is worse when I exert myself.”  It is a dreaded, and fairly regular occurrence.)

I turned.  Braced myself.  Planned to be firm with her.

“I know it’s off the subject,” she said.  I nodded.

She paused.

Her pauses are really long.

“Do you know that we are in end times?” she asked, finally.

“I’m sorry?” I said.

“End times,” she said.  “The end of days.”

This was not the kind of health-related question I had expected.  My mind raced, but I could think of no answer.  If I were to say, “no, I didn’t know that,” then that would be an implied invitation for her to impart more information to me.  By handing her the prescription I had reached my maximum tolerable level of unprofessionalism, so did not feel able to lie and say, “yes, I know that already,” then walk out the door.  On top of this, I rarely discuss nonmedical topics such as this with my patients.  I am there to be their doctor, and religion and politics could only interfere with that.  I have a few pat answers that I pull out when asked if I have accepted Jesus Christ as my Lord and Savior, or whether I know that God works through me, for instance.

None of my usual answers fit here, so a conversational hole appeared.  Luisa quickly began to fill it.  “I mean, you see the volcanoes exploding, and… airplanes can’t fly, and…”  She paused.  I began to recover, but before I could say anything, she went on.  “We have all these things that the scientists don’t understand, and it means we are living in the end times, that Jesus Christ is coming.  You read about this, I’m sure,” she said, smiling.  “I just wanted to make sure you were getting ready.  It will be very bad for you if you are not.  You should think about your family, too, and prepare them.”

I must thank God, if He exists, for making His warning about my erythromycin prescription so gentle.  That really was all that she felt she had to say, although she made it clear that she would be happy to continue.  My first response seemed to mollify her.  “Well, all any of us can do is to be the best person we can be today, isn’t it?  And tomorrow be the best person then, too.  And so on.  That’s what I focus on, myself.”  I tried to ignore the hypocrisy of saying this after having just been distinctly Unbest.

She smiled.  “You must pray constantly, to Jesus Christ, as well,” she told me, and took Annabella’s hand in hers.

I shook her other hand.  “Thank you,” I said.  “Do call if Annabella’s eyes don’t improve.”

“Oh, I will,” she said, and walked out.

After she left, I washed my hands very carefully.


*As always, the names and dates have been altered to protect confidentiality.

Got Milk?

March 24, 2010

Dear 17-year-old Nick:

I know this is not how you expected your life to turn out.  Better in some ways, worse in others.  The kids you probably figured would happen.  The smart, beautiful wife — well, you hoped you would get lucky even if you didn’t see the path that would lead you there.  Living in Cambridge, MA?  Sure.  Fine.  Things happen.

You’re surprised I’m a doctor.  Well, well.  Just goes to show that you don’t know everything, doesn’t it?  Sorry.  Just because you remind me of your/my teenaged sons doesn’t mean I need to get grumpy with you like that.  So, you think doctors are heartless robots, who have been focused on career and money since birth, and who don’t even realize they are in it to control others, huh?  Yeah, I remember very well how you think.

Well, I have news for you.  That is NOT the weirdest thing about this path you will choose.

Let me tell you a story.  Last week you (Hah!  That’s the pronoun I will keep using!   Deal with it!) saw a young woman whose problem was that milk keeps coming out of her breasts more than a year after she stopped breastfeeding her youngest child.  Foremost on your mind, believe it or not, was the worry that she might have a brain tumor.  Why?  It’s complicated.  And you’ll learn all about it, in about ten years.  Not the point of the story.

The point is that she says “breast” (“teta,” actually — you and she speak to each other in Spanish), and you think “brain tumor.” (YES, in English.  Quit interrupting.)  You don’t think, “breast.  Breast.  She said the word breast.  She has breasts.  Nipples.  Breasts and nipples.  Sex.  Playboy.  Girls’ breasts.”  You don’t think, “oh my God, what if I get a boner.  And she notices.  Help.  Cross legs.  Talk about something else, anything else.  Feeling dizzy.  Do not think about her breasts.  Do NOT think about her breasts.”  And then pass out from all the blood being diverted to your pelvis.

Instead you think, “bitemporal hemianopsia.  I wonder if she has bitemporal hemianopsia.  That would mean it is a pituitary MACROadenoma, not a MICROadenoma.  Don’t forget to check four-quadrant visual fields.  What else?  Medications.  Make sure no psychotropic medications.  That would be stupid and embarrassing to miss.  Also?  Could be nipple stimulation.  Must ask about nipple stimulation.  Causes feedback with even normal pituitary gland to release prolactin.  Should do breast exam to be complete.  I’m sure it won’t show anything, but yeah, fine, I’ll do it anyway. ”

This is not the weird part.

Then, you talk about all sorts of other stuff related to milk and brain tumors, including how much nipple stimulation she does.  It’s all very professional.  THEN, you examine her breasts, which — I swear to God — does not feel like a big deal to you.  Up and down, jabbering the whole time to reassure her.  “Normal, normal normal.  You know the tail of the breast goes up here between the clavicle and the shoulder?  When you examine your breasts for lumps make sure to check here too.”  You try to express some milk, and none comes out.  Thumb and index finger open, start behind the areola, gather the tissue together and then squeeze in and upwards towards the nipple, which is now the size of the tip of your index finger. Gentle.   Gentle.  Nothing.  No milk.  Whew.

You say “totally normal,” smile distractedly, leave, and she gets dressed again.  You come back in the room.

You tell her her exam is normal, that you couldn’t get the milk to come out so it might be something else instead, that…  She interrupts you.  She says, “oh, doctor, mire ESO” and whips her shirt and bra up.  Pinches just below her areola.  And milk SQUIRTS all over your face.

This is not the weird part.

She apologizes, reinserts her breasts into her bra, reassembles her shirt, while you rinse your face and keep saying “no problema.”

Here is the weird part:

For the next 24 hours you wonder whether this is constitutes a bodily fluid exposure, or whether your glasses protected your eyes and you don’t need to worry about infectious disease protocols.  24 hours.  Then, only as you describe this event to your wife (!), do you realize that it is not a normal daily event to have a relative stranger squirt her own milk at you with no intent of feeding you.

Worst of all, 17-year-old Nick?  You realize only then that this could be construed as erotic.  Only then.  Hah!  I shouldn’t be gleeful to tell you this, but I admit that I am.  I HATE thinking about you.  Now I have revenge.

Welcome to your life!  It’s all ahead of you.  Every last drop.

Posted in Medical
Tags: ,


February 7, 2010

Here’s my new book idea. My model is Atul Gawande’s fabulous books “Complications: A Surgeon’s Notes on an Imperfect Science” and “Better: A Surgeon’s Notes on Performance”. I’m trying to decide among the following titles:

“Worse: A Family Doctor’s Notes on Not Caring”

“Unforced Errors: A Primary Care Doctor’s Notes on Simultaneous Malpractice Charges”

or, simply, “Everyone Dies Anyway: Stop Yelling At Me.”

Posted in Medical
Tags: ,

Happens to all of us

February 4, 2010
1 Comment

“Sorry to rush you, doc.  The bus was late, so I missed the train.  I had to walk here from downtown.  The ATM ate my card.  People are assholes, aren’t they?  No one would give me a ride, and now I HAVE to leave in the next two minutes or I’ll be late for my sex offender’s meeting.”

Posted in Medical

Unsuffer This

January 31, 2010

(click for song):          Trouble

“I’m sorry to wake you, doctor, but we can’t find the heartbeat.  Can you come?”

“What heartbeat?  Ms. Evans delivered at five o’clock.  I don’t have anyone else in labor.”

“She’s here for a scheduled section, doctor.  I know she’s not yours, but can you please come?”

“Yes.  Of course.”  I looked at the clock next to my bed in the call room.  It was 6:35AM.  I had dropped like a doll on top of the blankets an hour earlier without even changing out of my scrubs.  I was exhausted, and had hoped to sleep until my replacement arrived at eight o’clock.

I turned on the light, splashed some water on my face, noticed my red eyes and bed hair in the mirror, let a twitch of self-conscious worry about looking professional seize me, smoothed my hair once, and then shuffled quickly out to the labor and delivery unit.

Rachel, who had teased me earlier by threatening to page me five minutes after I fell asleep, intercepted me at the doorway looking miserable and slightly scared.  “Sorry, Nick.  This is a 39 week nullip here for a scheduled c-section for placenta previa.  Hasn’t felt the baby move for 2 days.  Didn’t realize she should call.   Linda’s been all over her belly with the Doppler.  I checked it while she was calling you.  Nothing.  We thought you could take a look with the ultrasound.  I hope you don’t mind.  She knows something’s up – I didn’t want her to wait.”

I nodded, grabbed the little cart with the ultrasound on it, and wheeled it into the recovery room.  This young woman was here to have her first baby, was scheduled to have a caesarian section one week before the due date.  The placenta, which is like a tangle of roots and soil from which sprouts the umbilical cord and which normally attaches to the side wall of the uterus, covered instead the opening of this woman’s uterus.  If she were to labor normally, her dilating cervix could make her hemorrhage.  Statistically, 39 weeks is the time when babies are least likely to suffer complications, so here she was waiting today for my incoming colleague to give her a c-section.  Formal ultrasounds are done in the radiology department, but we kept a little machine in labor and delivery to confirm things like fluid levels and the positions of babies’ heads.

I opened the curtain to find a young Latina woman in the bed, johnnie lifted to reveal the large bulb of her abdomen.  Her face was heart-shaped, with a jutting chin.  Her long black hair was mostly gathered inside of a blue lunch-lady surgical cap, with one wisp stuck to her damp cheek.  Her eyes were dry, now, but clearly puffy from crying.  She stared intently into the eyes of the young man who knelt on the floor with his elbows wedged under his chest on the bed next to her pillow.  His two hands cradled one of hers, his stubby fingers interlaced with hers, stroking her hand with one thumb rhythmically, as he would a rosary.

“Hola,” I said, in my best calm, avuncular tone, and plugged the machine into the wall behind them.  They looked at me expectantly.  Pleadingly, or perhaps I imagined this.  “Yo soy Doctor Mayper.  ¿Español es mejor?  ¿Engles?”  I’m Doctor Mayper.  Is Spanish better?  English?

“Español,” said the young man.  Spanish.

So, in clumsy Spanish, I told them what they already clearly knew.  That the nurses were having a hard time finding the baby’s heartbeat, and that I was there to take a look with the ultrasound.  I felt relieved when they both continued to look worried as I set up, because that meant they probably did not hold false optimism.  Sometimes a new nurse like Linda might misjudge something like a fetal heart beat, but Rachel was a skilled and experienced charge nurse whom I trusted.  If she hadn’t been able to find a heartbeat, then there was probably no heartbeat to find.

I sat on the edge of the bed and turned the machine on.  Linda, a young blonde-haired woman with freckles and an upturned nose, whom I had vaguely dismissed during the few months she had worked here, hovered at the side of the monitor, fidgeting.  Rachel, an African-American woman in her late 30s with hair so straight that I wondered if she ironed it, a nurse both competent and so funny that I wished I could arrange my schedule to take call only when she would be the night nurse in charge, hung back frowning, arms crossed, rocking back and forth unconsciously.

As the monitor warmed up, I asked the couple their names.  Luz Martinez.  Jose Salvador.  I squirted the cold blue gel onto the flat tip of the ultrasound probe.  Adjusted the monitor so that we could all see, and pressed the probe against her belly.

Shadows and fuzzy gray lines played on the monitor, splitting and coalescing like a grainy black and white kaleidoscope until I got my bearings.  There the spine, looking like the crossties of a train track.  There the balloon of the skull.  Slide the tip of the probe over, as if massaging her belly.  The face with its dark eye sockets.  Slide the probe up.  That’s the abdomen.  Back toward the skull.  Back down.  Back and forth.  Narrow in on the chest, a sinking sensation in my own at the lack of a butterfly heartbeat.

My eyes, which had darted back and forth between Luz’s belly and the monitor screen as I got my bearings, now stayed fixed on the screen.  The back and forth sweeps of the probe shrank to tiny scooping arcs, as if it were a spoon and I were using it to scoop a beating heart from the bottom of a bowl of soup.

With each adjustment it became more obvious that this baby’s heart had stopped fluttering.  The monitor blurred and swam briefly as I blinked away tears.  There.  That’s two, four chambers.  Try another angle.  Yes.  Another angle.  My world had shrunk to this staticky image on a screen, of a heart that would not beat, in a shadowy body that floated passively as its mothers breathing turned to sobs, bobbing up and down like a corpse floating next to a wharf at high tide.

Not “like” a corpse.  A corpse.

My vision grew watery again.  As I stared at this calm, still heart, my head swam and my heart raced.  I looked at Luz, then Jose, as if seeing them for the first time.  Luz had covered her face with her free hand.  Tears crawled down Jose’s cheeks.  He clutched her hand to his mouth, squeezing it, his hands pressed close as if in prayer, staring at the screen.

I lifted the probe from her skin in defeat.  “Lo siento,” I said.  I’m sorry.  Gel lay smeared on her belly, heaped at the sides like plowed snow.  She peeked over her hand at the monitor, which of course now showed only static.  Her face folded at the sight as if in anger, then she clawed at her forehead with her fingers, pounded her eyes with her hand, and sobbed deep, gasping, gulping sobs.

Still holding the probe uselessly in my hand, tears now pouring out of me, I looked to Jose.  He still clutched her hand, but had moved it with his, pressed his thumbs against his forehead and rocked back and forth tapping against them as if in gentle mimicry of Luz’ pounding.


After the c-section I hung around to interpret.  The hospital has professional Spanish language interpreters, but the visitations of medical professionals kept leaving Luz and Jose with unanswered questions.  So I appointed myself general liaison from the arcane country of medicine.  I had no other responsibilities, and could afford to sit the whole morning with them after the c-section.  To be honest, I was there also because I couldn’t figure out how to cope with this horror.  It was a relief to find something useful to do.

I had scrubbed in for the c-section, as first assistant to my colleague Jean Baptiste.  Dr. Jean, as most people called him.  The boom box that usually sprinkles the room with quiet music during operations lay silent.   Words were scarce – just the bare minimum needed to keep the correct instruments flowing into and out of the operating field.  Luz’s body was covered with a sterile blue drape, With a circular window open in the middle to reveal her lower abdomen.   It inflected at her chest, and soared up like curtains to clamps a couple of feet above her body, hiding her face and head from our view.  Jose sat, wearing a yellow hospital gown and his own lunch lady hat, behind the curtain to be with Luz.  She was awake the whole time, of course, spinal block numbing her body from ribs to toes.

The baby was a little bit stiff as he came out.  Dr. Jean nodded to me as he cut the cord, and I lay the baby in the blanket held by the pediatric nurse behind me.  It felt surreal, this ritual performed every day with babies floppy or crying, now steeped in silence.  As the nurse swaddled him, I turned to Luz and Jose.  “Baron,” I said.  Boy.  Instantly I regretted the word, spoken out of habit.  How could this matter to them?  But, oddly, a small smile flickered on each of their faces before the deluge of grief returned.

The pediatric nurse brought their son to Luz, and held him close to her face.  Luz kissed his thick black hair, her eyes tightly closed with tears somehow escaping anyway.  The nurse gestured to Jose.  Did he want to hold the baby?  He opened his arms uncertainly, took the swaddled, lifeless body, then clutched his son to his chest and closed his eyes.  Rocked back and forth a little.  Softly murmured, “mi hijo, mi hijo.”  My son, my son.

The baby’s face was tinged, mottled with purple and red, and a little bit puffy.  As Luz had kissed him I had felt thankful that his skull hadn’t started to soften yet.  Sometimes, when the baby has died a long time before delivery, we need to wrap him or her carefully in a damp blanket, only the face exposed, the gelatinous head buried in folds of cloth.

His puffy face pinched his eyelids closed, as if he were trying to ignore us, as if in imitation of his parents’ expressions.  He had felt warm – a last gift from his mother – but stiffer than a living baby.  I couldn’t decide which was more disturbing – the warmth or the stiffness.  I had quickly checked his neck, his cord, scanned his body, but saw no sign of why he had died.  The placenta was normal, the amniotic fluid clear.  I wished he would look peaceful, but instead his puffy eyelids made him look vaguely annoyed.


As Luz was being cleaned and brought to the recovery room, I sat with Jose in a small side room and asked if he had any questions.

He asked, “¿Mi hijo… sufrió?” Did my son suffer?

I froze a split second longer than I would have wanted to.  Of course there is only one correct answer to that question.  “No,” I said.  I could imagine agonizing suffocation, pain incomprehensible to such a young, tiny person.  Such thoughts torture me sometimes.  But I could know nothing for certain, and my responsibility was to the living.

He looked at me.  “¿No cree que sufrió?”  You don’t think he suffered?

I pursed my lips, raised my eyebrows.  Closed my eyes to try to banish my own demon thoughts.  Shook my head gently.  Looked back at him.  “Se fue a dormir.”  He went to sleep.

Jose clutched his face, bowed his head and sobbed audibly.  I had not seen him allow such expression in front of Luz.  I reached out and patted his shoulder, crying again myself, thinking guiltily of my own three living sons.  He shuddered a little and shook his head.  I withdrew my hand.  Then, twisting in his chair away from me towards the wall, he let escape the same deep, gasping, gulping wail that had erupted from Luz earlier when she saw the blank ultrasound screen.

I sat with them, first in the recovery room where nurses came and went carrying sad faces, then in the postpartum bedroom where the nurse visits were interspersed with concerned specialists wanting to impart information, ask preferences, get signatures on permission forms.  The three of us had never met before that morning, but every time I asked if they wanted privacy they seemed sincere in their reassurances that they were happy I could stay.  When we were alone, I mostly sat in the corner chair, gazing out the window and looking back at them occasionally, wondering if I had betrayed Jose by covering up my nightmare fantasies about how their son had died.

They had to make decisions, the biggest of which was whether they wanted an autopsy.  The neonatologist, the head of the special care nursery, the chief pathologist, even the geneticist (who happened to be in the hospital for a meeting with the pathologist that day) all came to speak in somber but urgent tones about the benefits for future pregnancies, future babies, if Luz and Jose were to be able to understand what had happened this time.  No need to decide now, they were told, but the clock is ticking so please tell us as soon as you make your decision.  We’re so sorry.  We know this is a difficult time.

Then the specialists would leave, nodding at me, thanking me for interpreting, and Luz – usually Luz, except when she would nod at Jose as if to tell him it was his turn to ask something – would ask what felt like the important questions.

“¿Tienen que cortar a abrir su cuerpo?”  Do they have to cut him to open his body?

“Si.” Yes.

“¿Se lo puso de nuevo juntos después?”  Do they put him back together afterwards?


“¿Está seguro de que no se sentirá ningún dolor?”  Are you sure he won’t feel any pain?

“Si, lo prometo.”  Yes, I promise.  “Nunca se sentirá dolor.  Nunca.  Sé que estos médicos y que se amable y respetuoso.  Quiero confiar en ellos con mi bebé.”  He will never feel pain.   Never.  I know these doctors, and they will be gentle and respectful.  I would trust them with my baby.

This was all true.  I felt relieved to be able to say such honest reassuring things.

“Doctor,” Jose said after a long silence.  “Diganos lo que haría.”  Doctor, tell us what you would do.

“Esta decision tiene que venir del corazón.  Yo vivo en este mundo de la medicina, y no se puede imaginar a lo que la vida fuera de la que es.  Sin embargo, una autopsia puede ser la única forma de descubrir algo que podemos hacer para proteger a sus futuros bebés.”  This decision must come from your hearts.  I live in this world of medicine, and can’t imagine anymore what life outside of it is like.  But an autopsy may be the only way to discover something that we could do to protect your future babies.

“Gracias, doctor.  Mi esposa y yo quiero estar sola ahora.”  Thank you, doctor.  My wife and I would like to be alone now.


I visited them twice more during her stay, but the next time I visited the hospital they had already gone home.  I called Rachel – the first time she and I had spoken outside of work – and she told me they were planning to move back to Colombia as soon as Luz could safely travel.  They had asked to have the autopsy, and had arranged then for the body to be flown to their home in Colombia for the funeral.

I asked if she knew what they had named him?

Jesús, she said.  Jesús Salvador Martinez.


It was the following Sunday when I paid a visit to an ordinary-looking, white split-level ranch house next to the bay.  The house, which belonged to Jose’s uncle and aunt, was immaculately painted, the grass trimmed, small green shoots emerging from a garden plot in the side yard.  A pale blue boat resting on its trailer in the driveway.   A metal Christian fish ornament sticking to the rear of the pickup truck parked on the street.

Jose came out as I parked my car behind the pickup truck.  He waited at the bottom of the driveway as I walked down, then gave me a beatific smile as he took my hand in both of his and held it.  The bizarre thought that he was about to kiss me flashed through my mind, but he just nodded his head as he stared at my face.  My heart sank as I looked into the eyes of this handsome, poised young man who deserve so much to be gripping a baby boy in these hands, lifting him up against the clear sky in this warm spring air and listening to his squeals of joy.  But still Jose smiled.

He brought me past the garden plot to the back patio that overlooked the bay.  There Luz sat, like a queen in a white wicker chair, facing away from the late morning sun, strands of hair floating here and there in the breeze, wearing a pale nightgown and a peaceful smile.

“Muchas gracias por venir, doctor.  Significa mucho para nosotros.”  Thank you so much for coming, doctor.  It means so much to us.

I smiled for the first time, very slightly.  “De nada.  Tuve el honor que me invitara.  ¿Cómo se siente?”  It’s nothing.  I was honored that you would invite me.  How are you feeling?

I paused, horror stricken again at my mental image of her baby strangling inside of her, wondering how I would have felt about seeing the personification of my son’s death walk towards me on that patio.  I shook my head to clear it, smiled again, and said, “No solo su alma, quiero decir.  Espero que su cuerpo se está recuperando, también.”  Not just your soul, I mean.  I hope your body is recovering, too.

She nodded, her face returning to neutral.  Jose anxiously showed me to the chair he hoped I would sit in, so I gave her my painstakingly written condolence card and the white rose I carried for her, and sat.  We spoke of life in Colombia, of our frustration that the autopsy would likely reveal nothing, of my heartfelt respect for them as people.  They had been gracious to everyone, had let themselves feel the pain, yet had not seemed to let it ferment into poison.  They seemed to have no need to find a scapegoat.  I half wished they would have chosen me as a scapegoat, because then I could focus on that rather than the incomprehensible truth that had brought us together.

The visit ended pleasantly, and a little distantly.  Conversation lagged, I told her I hoped she could rest, and said I should go, implying prior engagement.  Jose quickly asked if he could show me something first.  Of course.  I held Luz’s hand in both of mine, wished her strength and peace and a happy life, then let Jose lead me along the rocky edge of the bay to a nearby pier.  Next to the pier a boulder jutted from the ground, newly chiseled rectangle holding a metal plaque.

The plaque read, in English:

Jesús Salvador Martinez

Born April 16, 2006

Died April 14, 2006

These were the dates written on the birth certificate and the death certificate that I had had to sign, one after the other, the previous week.

“Mi tía y el tío quería ser capaz de visitario.  Pensamos que tal vez usted querría eso.  Usted es bienvenido aquí en cualquier momento.  En cualquier momento.”  My aunt and uncle wanted to be able to visit him.  We thought maybe you would want that, too.  You are welcome here anytime.  Anytime.

He reached out with his hand to hold my shoulder the way I had tried to hold his back in the small conference room on that terrible morning.  He kept it there on our walk back to the house.

Kitty Cats and Hot Dogs

January 27, 2010

The vast majority of Americans spend a lifetime attached to their genitalia.  We think of these organs as urban dwellers who live in crowded neighborhoods.  The Boxer Tenements.  The Panty Projects.  The G-string Ghetto.  But really, our genitals spend a lot of time traveling.  We stuff them into our emotional baggage.  They lead us on crazy treasure hunts.  They fly with us on our guilt trips.

For those not fortunate enough to have lived with adolescent children, I have this message: Don’t Worry.  Your genitals may already be giving you the impatience, excitement, panic, pouting and raw confusion that you would hope for from your very own real teenager!  What’s more, a real teenager occasionally evolves into an adult and leaves home, but your genitals are attached to you at the hip!  Or, rather, between the hips.  I’m a doctor.  I should remember such details.

As a family doctor, in fact, I spend a surprising amount of time on the care and maintenance of genitalia.

These volatile teenagers between our legs don’t just keep us awake at night,

they don’t just want to make friends with all the wrong people,

they don’t just spend all morning sleeping when we would like for them to wake up and help,

they don’t just make messes then go to sleep, leaving us to clean up,

they don’t just embarrass us in public, with their jumping up and down and their sometimes wacky hairstyles.

They also get sick sometimes.  That’s where I get involved.

Well, to be honest, usually my involvement is more the equivalent of a well teen visit or a physical exam for school.  Lots of screening for cancer — of the cervix, the testicles, the prostate, the uterus.  Lots of talking to you about how to keep your permanent adolescent partner healthy.  Lots of mundane tests and treatments for the genital equivalent of colds and flus.  Most of the rest involves either supporting you in the process of delivering a real, detachable future adolescent, or helping to revive old Jumpin’ Jack.

Sometimes people come to me with wild problems or worries.  I’m not going to write about truly terrible or disturbing things here.  Those I usually need to refer anyway, to a blessed gynecologist or urologist who has the skills my patient needs.  But people find themselves in predicaments, or else wind up revealing more about themselves than they had intended.


Before this story, I have one anecdote more about a colleague than about his patient.  This colleague is a gynecologist who once told us of a patient of his who had shaved her pubic hair into the shape of a Christmas tree.

His main concern, when he told us about it?  “That young woman has WAY too much time on her hands.  I told her she should find a hobby, like macramé.”


For instance, many years ago, when I was a medical student, I “shadowed” a gynecologist, Dr. Huang, in his private practice in the tony neighborhood of Pacific Heights, in San Francisco.  “Shadowing” means that I tagged along while he saw patients, which can be a frustrating experience for male medical students because many women understandably would rather not have some guy in there gawking at them.  The first patient scheduled one morning was a middle-aged Japanese-American woman, Ms. Okada, who was there for a routine Pap smear.

As I walked in, I felt inordinately grateful to her for allowing me to watch such an intimate exam.  Then, when Dr. Huang lifted the sheet to begin, I couldn’t help staring.  Not at her genitals, though.  At her tattoo.

There, hovering just above her pubic hair, with slightly blurred borders on one side as if it had been skywritten above a forested hill, was written these words:  “Carl’s pussy”.

Carl’s pussy.  Dr. Huang, usually the most stoic of guys, paused.  He asked, “Who’s Carl?”

“Old boyfriend,” she answered in a flat voice.  She didn’t lift her head to look at us.  Silence returned.

Dr. Huang picked up the speculum from the warmer, then paused again.  “Had trouble remembering where it was, did he?”

There was the briefest of pauses, but just as my stomach began to drop with embarrassment for him, Ms. Okada grabbed her knees and sat up, her chest and face silently shaking.  She was laughing.  She tried to speak, but just then a tiny spurt of urine shot out and hit the speculum.  Her face, already deep red, started to shift to an expression of mortification, then almost immediately collapsed back into even stronger laughter.

Dr. Huang allowed himself a tight smile and small chuckle, then dropped the speculum into the trash can and reached for another.  Finally Ms. Okada regained her voice.

“I’m sorry,” she said.

“Not at all,” he responded.  “Do you often lose urine like that?  Maybe I can help.”

She ignored his question.  “Do you know, doctor, how many times I’ve been asked about that stupid tattoo?”  She pronounced it stee-YEW-pid.

“I can refer you to a dermatologist for laser treatment if you want me to,” he said.

Again, she ignored him.  “But I have never…”  She briefly shook again with laughter, and I noticed another brief smile flash from Dr. Huang.  “I have never… It’s just…”  She looked vaguely puzzled.  “He was adorable, actually.  It’s just that he was…  He was…”  She laughed again, but managed to finish with sort of a high pitched squeal.  “He… was… so… STUPID!”

When she stopped laughing again, she opened the top of the sheet and looked down at her tattoo.  “I thought I loved him.  He was not an intelligent man.  But I was young.”  She lifted her head and looked straight at me.  “Young is as bad as stupid.  Remember that.”

Posted in Funny/Odd, Medical
Tags: ,

Birth Story #4: Little Red Hen

January 25, 2010

Little Red Hen

In August 1996, a couple of weeks before Henry was born, an ultrasound showed that he had a distended bladder that would not empty. I was on call at the VA Hospital for my sub-internship when Sarah paged me with the news, and we spent the rest of her pregnancy stressing about whether he had a blockage that could potentially damage his kidneys.

Ironically, in order to visualize Henry’s bladder, Sarah’s had to be full. She had drunk a pitcher of water before coming to her appointment, then for two solid hours endured the near-constant squeeze of Henry’s body from inside and the ultrasound probe from outside. In this contest of urinary fortitude, Henry was the clear winner. Sarah finally begged to go relieve herself, while Henry kicked and swam, clearly enjoying the ruckus he had caused. A showoff before he had even been born.

Many anxious medical consults later, we were pretty sure that he was okay – maybe he would need a procedure to open his urethra soon after birth, but either way his kidneys looked fine and he should have a normal life.

Still, earth’s gravity increases for any parent whose child is in danger, and those last weeks were heavy for both of us.


We had moved, with our 3-year-old twins Isaac and Sam, into a communal house in Oakland that June with our friends Derek and Ted. Derek and Ted had been together for a couple of years, and were now looking to adopt a child themselves. Derek, in particular, dove into domestic life. That summer he was more involved in supporting Sarah and helping to raise our children than I was. He had taken her to that ultrasound appointment when Henry’s bladder became an issue, and he, Ted and their friend Shuman who stayed with us before returning for his senior year of college ferried the boys around Oakland when Sarah was busy.

Our household presented quite the picture. Sarah is even whiter than I am, with pale skin and bright red hair. Ted is half-Japanese, half-white. At that time Derek had finally convinced him to stop shaving his head, but he still had multiple piercings and wore a leather jacket festooned with metal doodads. Though his face in those days was often set in a scowl, he was actually the most committed of all of us to the constant human give and take involved in communal living. Shuman’s parents are first generation Indian immigrants who were still in full denial about his homosexuality even after he had come out to them the previous year. This summer, then, he had come to California to let himself breathe freely as a gay man. Ted and Derek loved to mock his every effeminate mannerism. Derek was the most visible of all of us. Half Filipino, half African-American, he is a large man who looks vaguely Samoan. With long frizzy hair that he sometimes braids and sometimes gathers behind his head in a ponytailed fro, a huge metal hoop through one eyebrow, often wearing a dashiki, and possessing a smile that makes the recipient feel like they just won a prize, Derek naturally dominates any room he happens to inhabit.

Despite our appearance, though, and our blended household, we felt quite conventional. Sarah and Ted taught at an uptight suburban high school in Silicon Valley, Derek and Ted worked ungodly hours running Quilumbo, the nonprofit educational organization they had cofounded, Shuman was a Princeton undergrad, and I was finishing medical school. Our visits to Costco involved two shopping carts and embarrassingly large packages of toilet paper, as well as one adult assigned to Sam and Isaac at all times as they ran through the hanging plastic slats in front of the freezer section or pleaded to build a fort behind the cereal boxes. The boys were the weirdest members of our household. At that time they were obsessed with gender, and would point at people and say loudly to each other, “Penis!” for man and “Vagina!” for woman. “She’s a vagina,” Isaac would say. “She’s got long hair.”

“Derek has long hair,” Sam would point out. “SHE’s a a vagina,” pointing at someone else. “She has a dress on.”

“No,” said Isaac. “Shuman wears a dress sometimes. And he’s a penis.”

This was all more than I could handle, so I always asked to push the shopping cart, claiming post-call fatigue.


One evening in the middle of August when I was on call again at the VA, Sarah began feeling contractions. A burst of domestic energy carried her through cooking dinner for everyone and washing the dishes, but when Sam and Isaac asked her to read them that summer’s favorite illustrated book “Sir Gawain and the Green Knight” she begged off. No one had offered to help her with cooking and cleaning, she said to them in front of Ted, Derek and Shuman, and now Ted would read them their story because mom needed to go have a baby. All three adults jumped up, falling over themselves to say yes, go, Derek you take her, ok I’ll take her, can I do anything else, really are these contractions, I’m so sorry, what else can I do?

Isaac and Sam, however, thought this was a terrible idea. They wanted mom to read the story, not to go have a baby. Mom grimaced at a strong contraction, though, said “ow”, and the boys were told to kiss mommy goodnight and come upstairs with Ted. Who would read it two times if they wanted. This worked for them, and they tumbled up the stairs asking “three times? Can we have it three times?”

So, Derek drove Sarah across the Bay Bridge to Kaiser Hospital in San Francisco, while Ted read and reread and reread the story of Sir Gawain keeping his promise to return after a year to the Green Knight’s castle to let the Green Knight chop his head off, each time asking the boys, “Is it important to keep a promise?” Each time listening as the boys solemnly swore that they would keep promises, too.

Meanwhile, Shuman paged me at the hospital to tell me that Sarah was in labor, which is far more difficult and painful than just having one’s head chopped off. Though I felt guilty at signing out my work to Jose (my supervising resident) and leaving, this birth represented a promise of mine far more serious even than ritual execution, let alone writing admission orders that could be written by somebody else. Luckily, Jose agreed, and shooed me off the ward.

In a crowded elevator on the way out, one of the other residents learned I was leaving because my wife was having a baby. He asked, “is it your first?”

“Third,” I said, distracted.

“Third?” he said, looking shocked. “What are you? A Mormon?”


Meanwhile, Derek brought Sarah to the hospital. Her contractions were becoming more painful as they got there, and the walk up the hill from the parking lot in the freezing foggy wind felt Sisyphean. After they got to the E.R. and were told to go to the Labor and Delivery ward, she had yet more climbing. Up three flights of stairs and down an infinite hallway with no offers of wheelchair or even of help. Derek offered to carry her at one point, and they both burst into laughter at the thought of it.

Finally she arrived and was waiting to be triaged as I rushed in, still wearing my VA scrubs, scared that I had missed the delivery. Derek said goodbye and left to go retrieve Ted and Shuman, clearly anxious to avoid missing the birth as well. We had asked a friend, Inga, to stay with the twins because all of our housemates were dying to be in the hospital for the birth.

The nurse showed Sarah into the delivery room at about 11PM. A distracted resident came in, checked her cervix, and pronounced her to be 3 centimeters dilated, that she was far from delivery, and that she should go home for a couple of hours and then return if the contractions continued. Almost as soon as she left the room, though, Sarah started screaming in pain with each contraction. It was horrible to watch, and I still can’t imagine how she endured it. Henry’s head was facing the wrong way, and once it was low enough in her pelvis each contraction squeezed the back of his head against her tailbone. It’s as if the back of her pelvis were caught in a vise, being bent outwards with just short of the force required to break it.

As a physician, I see people in pain all the time, but rarely have seen anything more intense than the next couple of hours were for Sarah. Changing positions, whimpering, screaming – my WASPy, undemonstrative, socially correct wife actually screaming out loud in public – none of these made her contractions tolerable. Unfortunately, when I left the room to ask for help, it was as if there had been a bomb scare. Just the unit clerk was visible, and she had trouble finding a nurse who could help us. To make matters even worse, there were multiple emergencies happening at that moment – 2 caesarian sections, and God knows what else – and no doctors were able to come reevaluate Sarah for over an hour.

So Sarah labored alone, with me wracking my brain for tidbits from my OB/GYN clerkship the year before that might help her. Preparing myself for, God forbid, the need to deliver our baby on my own if need be. The room felt that isolated, and help that unavailable. She tried the rocking chair, leaned against the wall, and finally (I kicked myself when she found this because only then did I remember that this could help) perched on elbows and knees on the bed, bottom sticking up into the air, rocking back and forth during contractions. This last position was the least intolerable, and when my frantic and eventually angry toing and froing from room to nursing station finally drew a nurse to come in, Sarah refused to change out of that position even to sign papers or change into a hospital gown.

She begged for epidural anesthesia, as the nurse said irritably in her Philippine accent. “Doctor will be in soon. Not so loud. We have to wait for the doctor to evaluate you. You are disturbing the other patients.” Finally, as the nurse was placing Sarah’s I.V. between screaming contractions, “Doctor” did come to evaluate her. It was a different resident this time, which was a good thing because I wanted to throttle the first one for abandoning Sarah. She checked Sarah’s cervix, and announced that Sarah was too far along, and would not be able to get an epidural.

Sarah’s face transformed. “WHAT did you say?” she asked, glaring at the resident. Sarah, who is so afraid of behaving poorly that she once apologized to a man who rear ended her at a stop sign, looked like she would cheerfully throw this resident through the window for even thinking of denying her epidural. The resident shrugged.

“You’re 9-1/2 centimeters dilated. You’re going to have your baby before you could get an epidural.”

So Sarah bowed her head, and screamed her way through the last few contractions before she could start pushing. Pushing made her feel better, and the resident asked her to turn over and lie on her back to deliver the baby. Henry’s head must have spun to face the right direction by this time, because Sarah was able to focus on her pushing, red-faced and concentrating, rather than writhe around screaming in pain. Sarah and I had hoped to have my hands on Henry’s head as he came out, and had prepared a little spiel to justify it, then abandoned that thought when Sarah was in her agonies. Now this hope revived, and I suggested it to the resident, who calmly nodded and asked me to put on sterile gloves.

I had only delivered a couple of babies during my OB/GYN clerkship, which was why I had felt terrified at the thought of delivering Henry on my own, but this worked perfectly. I put my hands on his head as it finally emerged, anxiously focusing on the textbook pictures I had studied about where to press and when to do it, while the resident covered my hands with hers and shielded Henry and Sarah and me from my inexperience. Briefly Sarah’s eyes caught mine between pushes. Through my anxiety, I saw her pride and love, and then focused back on Henry’s emerging head with a twinge of confidence.

Sarah pushed Henry’s head out into our hands. The resident delivered his body. Henry cried, but not before I did.

I brought him up to Sarah as the resident cut the cord. I put him on Sarah’s chest, and the three of us lay together for a moment. Warm. Gentle. A family. I kissed Sarah and told her how amazing she had been. She kissed Henry and said “Hello!”

His hair was red. His skin was pale. No one would need to check I.D. bracelets to be sure that this baby and mother belonged together.

Soon, the pediatric resident grew anxious, and asked to bring Henry to the warmer to evaluate him. I followed them. She did her initial exam, then turned to do paperwork. I remembered his bladder then. Felt that bolt of fear return. Reached down to the warmer to feel his lower belly for the mass that belies a distended bladder. Pressed there.

An arc of urine shot from his penis as I pressed, all over my hair and forehead. I yelped and ducked, too late. I looked at Sarah, who started to shake with laughter. “I think he’s ok,” I said, and laughed too.


A little while later, while I was in the bathroom washing Henry’s pee out of my hair and then emptying my own bladder, the unit clerk came in to ask if three men could come in to visit. I had completely forgotten that Ted, Derek and Shuman would be waiting outside. Sarah and I both said, “Yes! Of course!” We found out later that Derek had talked the nurses into letting them in far enough to watch the contraction monitor. They had proudly noted to each other that Sarah had the biggest contractions of any of the laboring women there that night, but had grown agitated when the tracings suddenly stopped. They were worried that something had gone wrong, and had not expected that Sarah would have delivered Henry quite yet.

The clerk paused, with an uncertain look on her face. “You aren’t…” she began. We waited. “Do you belong…? Are you in of some…? Are you members of some sort of group?” she finally asked.

Sarah and I looked at each other. “No,” Sarah said. “Why do you ask?”

The clerk looked a little embarrassed. “Oh, well sometimes we get people… Um. It’s just that you all live together, and we like to be sensitive here. That’s all.” She smiled quickly.

The three men entered the room, Ted with his skull freshly shaved and wearing both a rat skull earring and a huge grin, Derek in beads and braids, wearing an embroidered African tunic, and Shuman looking quite conventional above his plaid kilt.

Sarah looked at the clerk and said, “No. We just promised them that they could be here. It’s important to keep promises.”

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