Memorable Patient Encounters 2

There are good days and not-so-great days. Last month, I got a bit of a shock when two of the mothers I had counseled admitted their kids to the Neonatal ICU (NICU) for dehydration, hyperbilirubinemia and excessive weight loss. Of course, all these are direct causes of inadequate breastfeeding.

I had seen one of them once briefly and the second one, about whom this post is about, I had counseled extensively and multiple times, along with her whole family. To say that I was dismayed to see her in the NICU with a sick baby would be an understatement.

Sometimes issues with language, understanding, culture etc are vast, or they seem so. This lady came from a very poor family. That per se doesn't mean anything. Intelligent, capable women are found everywhere, regardless of their family situation.The language of communication was Hindi, not my strong point; the differences in education, financial situation, family stability etc were of course clearly present. But these I have been able to overcome before, but somehow was not able to do so in this case. There was no rapport. Usually, if I find it difficult to communicate with the patient, I turn to her mother since she will be the one who's helping the new mom. Speaking to this patient's mom was just as difficult. There was a brother as well, and he was actually easier to talk to. Very interested in his sister's ability to breastfeed and the suckling ability of the baby. Usually when a male family member interests himself in the breastfeeding process, it's the father of the new mother or the father of the baby. Having a brother so keenly asking questions was surprising, but who am I to judge? I actually was grateful that someone in the family seemed to understand and respond to what I was saying. Many times I wondered if I was getting through to them, despite the head nods and the smiles, but then I dismissed my concerns, assuming that everything would be fine. She had an inverted nipple, but was feeding the baby through a nipple shield. She seemed comfortable, the baby appeared to be feeding well, was peeing well and there was a slight weight gain by the time she and the kid were discharged.

And then of course, a week later, she turned up with her little baby to the NICU.

Anyway, counseled her again in the NICU; she was defensive, not willing to think that there was a problem; and then all of a sudden, burst into tears about her father... she sobbed and spoke through her tears. I was unable to understand if her father had recently died or had abandoned them, or if all these events were in the past which she was still grieving over. At the back of my mind were all these questions: where was her husband? What was the brother's role? What was going on?!
Very confusing. And it happened right in the middle of the NICU; all the sisters stopped, stared, exchanged bemused glances, whispered among themselves and I was trying to console this lady and was wondering what I had said that set her off.

After some time, and a lot of coaxing and fake cheerful-talking, things returned to normal, or as normal as they could get. Turned out she wasn't eating properly- they were keeping her on rice and dal because she had had a cesarean section (were they punishing her or were they simply misinformed? Usually maternal diet after childbirth forms a pretty key part of my standard spiel... did I somehow miss talking about this with these guys?), she was not eating or drinking properly. Imagine- 3 meals of just rice and dal; not even with ghee. Restricted water. How is anyone to survive on this nonsense, let alone make enough milk to feed a newborn?

Later I found her brother in the vicinity and questioned him. And he said, "Yes doctor, you had told us about what to give her and what she should eat" (ok. good. so at least I hadn't missed that) and then I reiterated again about what she should be eating and how important that was.

God knows what happened after her discharge from the NICU. I hope she doesn't turn up again at the NICU and that baby grows a bit and this whole breastfeeding thing resolves without any more issues.

Ideally, I should have asked her to come meet me on an OPD basis to follow up with the lactation. But I was frankly very reluctant. I am a simple lactation counselor, that too with no qualifications other than an LCCE, a bit of experience and a true desire to do this stuff. All the psychiatric stuff, the financial stuff (they might feel obligated to come see me, but may not be able to afford the OPD fees), and most importantly, the getting-through-to-them stuff was too overwhelming for me. So I gave her my card with my number on it and asked her to get in touch in case of any issues, but didn't set a time.

Reading this account over makes me realize how out of control I felt. Most of my decisions were made based on a desire to get out of the situation rather than meet it head on. This is something I will probably come across again. So I must learn to become more aware of these obstacles. I must talk to Rk and other doctors about how they handle difficult cases.

Spousal relations

Does anybody else ever wonder how the rest of the married couples in the world seem to get along just fine? Barring the "clearly unhappy to be together" couples, most reasonably happy pairs seem to have figured out how to communicate.

Despite RK and me being fairly articulate, proactive, decent communicators in every other sphere of life, there are times when we clearly have no idea what the other is saying. I could be speaking in Swahili for all that it mattered. And he would be spouting words that make sense by themselves but have no meaning when strung together. And even if the words make sense, their meaning is sometimes shrouded in mystery. And many times the meaning that makes sense is only the most superficial and there are layers and layers of nuances buried underneath that are to be unraveled.
How the heck do other couples manage this? How do they figure it out or fight it out?

That's the other thing I'm grappling with. Now that our kids are old enough to understand many things that I sometimes wish they wouldn't, I'm trying to become more circumspect about arguing with RK. No more yelling, screaming, crying, throwing things, stamping feet, threatening bodily harm... you get the gist. Now it is all saved for the car after the kids go to school. Even then, traffic in Bangalore being what it is, one is never more than a foot away from the deeply interested observers gazing from behind their auto rickshaws or motorcycles. This means that while you are hissing threats or abusing your spouse's intelligence, you have make sure to keep a smile on your face.
And forget about having a good loud argument at home... you might as well just shout it out on a loudspeaker to the whole neighbourhood.

Come to think of it, if there's one thing I miss about Pittsburgh, it's my house and the utter privacy of it. Yelling at kids, yelling at spouse, yelling just for the heck of it... you could do it all and be assured that not one word would escape your four walls.

I've been watching other Indian couples and how they interact and I can't say that it fills me with much hope that RK and I will magically figure out how to communicate flawlessly. Either one partner gives in to save face, or the argument flares and dies down very quickly. There's no drawn-out, let's-really-dig-into-this-matter-and-unearth-every-single aspect-that-needs-to-be -changed-in-the-history-of-this-relationship kind of an argument that other people (for instance, yours truly) seem to enjoy.

God knows I tried to change myself so we wouldn't stick out among all these couples. I did the "let the man talk and I will listen quietly and leave" method and the "let's say this and get out quickly" method, both of which confused and indeed, offended, RK no end, with the result that we circled back to our usual formula of argue, fight, vent, rant, tears (on my part, since I really turn on the waterworks), ending with long monologue (on RK's part, since he is the monologue champion), laughter and a promise to try better next time (on both our parts). Phew! It's a real emotional wringer of session, which is why I try to avoid it as much as possible, even though many times I know it's going to blow up in my face.

What I need to find is a couple where one partner is high maintenance, doesn't like to do much work around the house, is fairly involved in whatever they think is important and that's it. I might find my role model.

Article on Respectful Obstetric Care

My article on respectful obstetric care is now online on Perspectivo Mag!!

Comments and suggestions are welcome!

Memorable Encounters- I

I used to read James Herriot many years ago. He had expressed a thought frequently in his many books, the truth of which I am realizing in my own life now. He said that he would have seen many, many patients, but a few always stay in the mind, who stand out clearly in the nebulous seas of memory.

Among the people I recall are two ladies: a daughter and her mother.
The daughter had just given birth and was suffering from engorgement of breasts, which was why she had been referred to me. This patient was in her mid-twenties; the baby who was born was a "precious baby". Of course all babies are precious, but this phrase is used to describe any baby who is born after many trials, miscarriages and so on. This lady had had a stillborn some years previously, multiple miscarriages, abortions etc and who was thrilled to finally have a live, healthy baby in her hands. Her mother had been making her drink garlic milk for a few weeks before the childbirth to increase her milk production. She felt that that was the reason why her breasts were so hard and painful.

So we chatted, I told her all the usual steps to decrease the engorgement, such as warm compresses on the breasts, frequent hand expression of milk, frozen cabbage leaves (!) and paracetemol for the pain. Just as I was about to leave, her mom said, "Doctor, can we try jasmine?"

I blinked and said, "Okay, why?"

She said, "Why, to decrease the milk flow, of course"

I frankly admitted that I had never heard of jasmine having an effect on breast milk and then she said,

"It's a very common thing in our tradition. Every time the mother needs to decrease her milk, especially in case she no longer has to feed the baby, we tie a garland of jasmine flowers around her breasts and by next day, her breasts will be empty"

"Really?" I ask. "What if she wants to get the milk again?"

"Then she just has to start breastfeeding and drink a lot of garlic milk", said the mother.

Later that evening, I googled this up and sure enough, there were a couple of papers that talked about jasmine flowers affecting prolactin, the hormone that stimulates milk flow. I also spoke to a very experienced pediatrician who agreed that this really worked. What is unclear to me, however, is how long-lasting the effects are and if they can truly be reversed with substances like garlic, which are known to stimulate milk, and how long the reversal process takes. 

Weeks later, someone else told me that jasmine flowers are never given to a new mother, for this same fear. Jasmines are not even kept in the same room, apparently.

Interesting, right?

A Muslim family told me that they feed the mother the udder of a mother-goat. Apparently it looks a bit like paneer inside and one chops it up, roasts it and makes it into soup. And a couple of days later, milk starts leaking out of the breasts like water from a tap!

The things you don't learn from a text book.... :)

A Picture Worth Your Time

What a stunningly powerful picture.

I saw it on the Washington Post. Copyright belongs to Johnathan Bachman/Reuters

The caption is pretty brief: A demonstrator protesting the shooting death of Alton Sterling is detained by law enforcement near the headquarters of the Baton Rouge Police Department in Baton Rouge, La.

Flavours and Personalities

Ahem. Kindly note the added 'u' after the 'o' in the heading above- an added sign that I'm becoming truly re-Indianized. This, of course, means that I can no longer take comfort in 'diarrhea', but will have to switch the unwieldy 'diarrhoea'... Not that I suffer from either, at least not currently anyway. But in case I did and for some reason, needed to write about it to someone, I can no longer zip off the shorter version (of the word, not the deed) without feeling like I was somehow cheating.

Anyway, I was impelled to write this blog (that too on my phone) after visiting a patient. Have I mentioned how much I love meeting patients? There's of course the obvious attraction of sounding oh so important when you can throw around the phrase 'need to see my patient'- do doctors still retain that kick out of saying it after years and years of doing so?- but to me, a basic bench scientist for donkey's years, there's the sense of astonishment and boot licking gratitude that I actually am seeing and talking to so many different people every SINGLE day!! To think that I spent more than a decade huddled under sterile hoods and hunching over lab counters, desperate to escape and resigned to never actually escaping, this freedom to wear something other than jeans and shirts and shoes that cover every inch of foot skin, to touch something without wearing gloves at work(!!), it's indescribable. If I had to try to describe it, I'd say it's like that feeling of well-being, you know, long-lasting relief that you get when you empty out your bowels after waiting a long time to do so.

Anyway, the main point of this entry was to reflect on the various personalities one comes across. Postpartum periods are funny- women are simultaneously stressed out and happy; they have a sense of completion (or sometimes, accomplishment) that the labour part of it is over and they are now anxious about how to get this kid to feed. So it's always interesting to see how women handle this period in so many different ways.m

More about this in the next post... My phone is dying.

School in India

To be sung to the tune of "We Didn't Start the Fire"

Brown paper wrapping

Sello-tape, label-sticking

Uniform buying

Tie, belt and badge hunting.

Early morning prayers

We worship all Gods,

(Some Gods more than others)

Religious tolerance in action.

Waiting outside school gate

Fine for coming late

Shoes not sparkling white

Go hide out of sight.

(We didn’t start the fire)

This is school in India

There is no complaining, only early waking.

School bag packed with books

Weighing at least 10 kgs

Who says it breaks kids’ backs?

We believe in weight lifting.

Lunch in steel box

“No plastics” bandbox

Where is my steel thermos?

Is plastic basket allowed?

PT, langdi, running race, kabbadi

Annual Day, Sports Day (JFK blown away, what else do I have to say?)

This is how we celebrate!

(We didn’t start the fire)

This is school in India

There is no complaining, only early waking.