Rareified Air

I've never in my life used the term "rareified air" and I don't even know what it means. But all I could think as I rode my bike along Lake Washington this evening is that the air was rareified. Not only are all the houses on this route gorgeous, and have beautiful, overflowing cottage gardens, but the air itself actually smelled like honeysuckle and ocean. I got the lovely nostalgic feeling of being at my grandparents' house on the sound in Florida, the same feeling I get every time I smell Yardley of London Lavender soap (the only kind my grandmother uses, and what was always sitting on the stump next to the faucet where we soaped up and hosed off after playing in the sound all day, before we were allowed to come into the house). I also get this feeling whenever I see one of the extra-gigantic (2 gallon?) plastic buckets of ice cream at the grocery store. I always resist the urge to buy them because, hey, I don't need to eat 2 gallons of ice cream. But I long to see that big plastic bucket in my own freezer, and later to use it for compost. My garndparents always had the big bucket of ice cream (makes sense with 7 grand kids and their parents always at your house), and when it was empty, it became the compost bucket, which my grandfather would take out after cleaning the kitchen with a grandchild after dinner. When I was a teenager and still lived at home, but could drive, my grandparents no longer lived at that house, having been flooded out of it by every hurricane for the past 25 years or so. But I would still drive over to that house and park across the street from it, looking at it, when I was really upset or had a bad day.

Life Tasks vs. The Big Picture

Several conversations over the last few days have made me think about what life should be like, who I want to be, who Alex wants to be, who we want to be together. My mom was making a "bucket" list (I made one a while back, you can see it in my July post from last year). But as I was looking over it just now, and talking to Alex, I was realizing that what I want is not to neccessarily accomplish this certain list of tasks. What I'm going for is a lifestyle, which I can kind of get a picture of from looking at those tasks.

I want my life to be a little bit like a Nikki McLure print, I guess. I want my life to be oriented towards adventure, enjoying the small things, being together with Alex and growing our relationship over the decades, learning from life and other people and growing spiritually, appreciating the passage of the seasons, communing with friends, building community, giving service to others-loving life and sucking the marrow out of it. I've always told people that I am a very visual person. I have to be able to actually see myself doing something or being someone in order to make it happen or to feel that it's right. So when I look at my life list I see myself riding my bike to the farmer's market in Columbia City, having coffee on the porch with Alex, making dinner with a crowd of friends, picking raspberries and sweet peas in the garden, being an excellent and compassionate midwife, going stargazing with Alex and making out on the beach.

Having the life list is helpful because it helps me see what the vision is, and maybe it will help me check in with how I'm doing. Since there will no doubt be hard days in any life (how else would we learn, and deepen connections with our loved ones), knowing that I am generally on the right track will be good. Here is my somewhat updated life list. It's scary to let go of the old one, becuause I worry it means I'm never going to accomplish anything with this everchanging goal. Ain't that life, though?

Near Future:
1) Keep fresh flowers in my house
2) Shop at the farmer's market
3) Grow our own food, and preserve for the winter
4) Remember to send cards and little gifts on people's birthdays
5) Kill my TV for good!
6) Learn to play the cello and/or the fiddle
7) Host a Love Feast
8) Go ice skating every winter, pick berries and fruit every summer, bake cookies and press leaves in the fall, cut our own tree and decorate like crazy for Christmas, dress up and hand out candy at Halloween, go all out for Thanksgiving Dinner with lots of family and friends, make Valentines cards and cookies for friends and family...
9) Try rock climbing
10) Be a trail runner
11) Make a budget and stick to it for a year
12) Hike a National Scenic Trail with Alex
13) Do yoga at least once a week for a year
14) Use my bike for 90% of my transportation
15) Fulfill my wedding vows every day
16) Go on a date once a month
17) Bake our own bread
18) Make out with Alex at a drive in movie
19) Go on a weekend road trip with Alex
20) Maintain close friendships and let my friends know how much I value them
21) Go stargazing with Alex and make out under the stars
22) Camp on a beach in the Fall with friends

Long Term
1) Be a kind, loving and faithful wife
2) Be an excellent, compassionate, skilled midwife
3) Be a foster parent
4) See Alex hold our baby
5) Volunteer at a hospice
6) Have my babies and grow old in one single house

Standard Issue Nurse

I bought my UW purple scrubs a few weeks ago. And a white coat. Oh, the white coat. That symbol of authority and knowledge, of professional solidarity . I am at once proud that I will soon be wearing the uniform of a health care professional, and extremely cautious about it's meaning. I just want to be clear with myself about what kind of provider I'm going to be. I think I need to be pretty solid about my core beliefs and values before I start the standardizing process of nursing school.

There are advantages to standardization. It's nice to know that no matter where you get your care your privacy is protected by HIPPA, and your physician is somewhat bounded by standards of care. On the other hand, our health care system is not as uniform as one might think. There are huge variations in policy and treatment from one hospital to another, and even from one provider to another in the same institution. One week at Evergreen, moms with epidurals can use a squat bar and eat popsicles. The next week they're flat on their back for the duration, and it's ice chips only. One Group Health provider says 4cm and contracting every 5min is not even active labor. Another says if you do this for more than 12 hours you need a cesarean for failure to progress. So, standardization is at once a blessing, a curse, and an illusion.

Nursing school and medical school seem to be designed not only to teach providers the physical and mental skills, the facts, figures and flowcharts of their professions, but to teach them a certain belief system about their profession and about patients. It involves a little bit of de-humanization. Maybe you have to be a tad arrogant and a bit emotionally removed to take people's lives into your hands. I guess all I know is this, that I want to keep a few things about my beliefs and my humanity intact, regardless of what I learn in school. Even if I look like everyone else, in my purple scrubs and white coat, I want to hold onto what makes me human, and passionate about health care in the first place, and what grounds me. So I think I better write it down before I even start school.

1) We all, every one of us, deserve compassion, dignity and respect.
2) Just because I know some things about the human body does not mean I know more about my patient than they know about themselves, and does not make me superior in any way.
3) An ounce of prevention is worth a pound of cure.
4) People make good decisions for themselves, when provided with the information and resources they need to make those decisions. If it's not the choice I would make, that's Ok because it's not my choice to make and I'm not the one who lives with the consequences.
5) Most of the time, people need you to listen long and hard before you speak.
6) It's OK to say you're sorry.

Defensive Doula

You often hear about "defensive medicine." Providers who at the very least, chart every possible interaction and occurance with their patients so they are somewhat protected if the patient later sues for a bad outcome. At worst, providers use an intervention just to say they did something, which is thought to be better than doing nothing. Lately I feel like I've been practicing defensive doulaing.

I've begun to feel like, when I attend a hospital birth, the doctors and staff very much assume that my client will have an epidural, pitocin, and very possibly a cesarean. They are justified in the assumption: at one local hospital, 90% of women have an epidural, adn 36% have cesareans. When 90% of your patients have an extremely abnormal birth, abnormality becomes the new paradigm. The staff at the hospital with the highest epidural rate is clearly uncomfortable with normal birth. All the moaning, all the pesky position changes, the sheer duration of a normal birth. They are uncomfortable with women in pain, women who are tired, women who need emotional interaction and support. They are so used to an immobilized, chatty, TV watching laboring mom that when my sweaty, moaning, vomiting and shaking, hip rocking, crying, squatting, normal birthing mom is in the room they feel they must DO something. And what do they know how to do? For a while they might sit next to a bed (where many women assume they must stay during labor, or are stuck with a routine IV and fetal monitors) and tell a woman to "just relax, breath it out." But, they have other things to do, and I really get the feeling that many of them think the idea of unmedicated birth is just heinous, an unnecessary cruelty. And if you offer a woman in that much pain an epidural, they have an awfully hard time saying no.

Anyway, lately I've been feeling like I need to prepare my clients, really, really prepare them, to defend themselves from the new normal. Wait to go to the hospital until the last possible moment in labor. To say no (repeatedly, confidently, and assertively) to pretty much everything the staff tells them they 'have' to do. To close their ears to the innumerable discouraging comments, and to close their legs to the innumerable, discouraging, and pointless-unless-you're-in-a-hurry vaginal exams. I've even resorted to encouraging the use of very defensive, almost legal language in birth plans, to put the fear of god and litigation into the staff. "I DO NOT CONSENT to any cesarean that is not an emergency." Telling patients they might want to cross out the section of the admitting paperwork where they sign a general consent for a cesarean. This is not stuff that encourages the team spirit, mutual respect, and collegial vibe that I have always worked for in my relationships with staff.

Although I'm not happy about these ways in which I've changed my practice, I'm not ashamed of them. There are changes, however, that I am more worried about. These are where I am truly taking on a practice similar to defensive medicine: I'm doing something (something I don't even believe in) just to do something, to change my clients behavior because I can't change the providers' behavior. I'm ashamed to admit that I've used directed, purple pushing with unmedicated moms, because I know we have 3 hours to get the baby out before the staff start to move for a cesarean or if we're lucky, a vacuum. An unmedicated mom with a good urge to push may take 4-5 hours to push her baby out, both mom and babe are perfectly healthy, and she pushes when and how she feels she needs to. Lately I've told moms that they're better off to flat out lie to staff about their pain, frustration, or fatigue. Of course the mom is tired. That is NOT a valid reason for major abdominal surgery. Even worse, telling women you think they are too tired to push at all, before they even try, and before they have said boo about being tired. I feel terrible encouraging my women to change their normal birth to save them from an abnormal birth. Wait forever to go to the hospital so that you have to practically crawl down the hall in transition. Furitively sneak gulps of apple juice when the nurse is out of the room. Outright deny your perfectly normal feelings of fatigue, frustration, uncertainty. Lie when they ask you to put your (level unspeakable) pain on a 1-10 scale and say it's not too, too bad, maybe a 7. Lie and say you aren't at all tired when it's time to push, say you have all the energy in the world. Because the staff has 0 faith in women's ability to give birth, they latch onto the slightest indication that she too is doubtful, and exploit it to push intervention.

All of this bugs me on the obvious level that it is unjust for the laboring woman. But it bugs me in a more insideous way too. Because I am not a rule breaker. I am a rule maker, a rule follower, a research and science and fact junkie. I'm the kid who cried when I was even mildly scolded for breaking a rule. I'm not one of those fanatical, radical, 'use nothing but your intuition to make decisions about your birth' people. I believe firmly that there is a time and a place for everything, including epidurals, pitocin, and cesarean birth. I believe that we should base medical recommendations on good research, and that clients should base their decisions on solid, honest information about the recommendation, the alternatives, and the risks and benefits of each. It bothers me that sometimes I hear myself talk about birth, and I hear the voice of a frustrated fanatic, not the logical, down to earth, pragmatic person I am. Of course it bothers me that believing a woman in labor has the right to full informed decision making makes me sound radical.

Moreover, I have to walk a very fine ethical line between my scope of practice and standards of care as a doula, and doing what the situation demands to defend my clients from ridiculous hospital policies and bad provider attitudes. It's hard on my self image; it's hard on me emotionally to go to births where I feel like the woman is truly treated unjustly, and it's hard on me to feel like I'm constantly toeing a line between actually helping my clients get good, healthy outcomes, and stepping outside of my very restricted scope as a doula. Technically as a doula I am supposed to "protect the woman's memory of her birth, recognizing that birth is a peak life experience." But I am quite sick of trying to protect women's memory of their unneccessary cesarean. And it's hard to qualify an afternoon spent napping, doing cross-words, and watching TV as a peak life experience, even though it does end in a new human being.

I'm doing my best, and I'm not sure I'm doing enough. That sucks, because I care. A lot. About birth as a peak life experience. About the health of moms and babies. About the way a woman remembers her birth and perceives her strength in birthing, and takes that memory and knowledge of how strong she is, and uses it to get through sleepless nights, teething, smarty pants eight year olds, snotty teenagers, sending her baby to college, supporting her daughter when she has a baby of her own. It really, really matters.