Your Heart is the Size of Your Fist

by Martina Scholtens

  “Don’t hang up,” I said. “We won’t talk anymore about what happened to him. We’ll move on to asking about his mood and sleep.”

  I spent the next Saturday morning composing the medical legal report, as I’d written dozens of others over the years. I outlined my credentials, stated the trauma history provided by the patient, detailed the physical injuries, and commented on any psychological distress. I described Li’s scars in painstaking detail and emailed a draft report to the lawyer.

  Thomas Striker responded on Monday morning. “Could you state definitively that the scars were sustained from beatings with electric batons?” he asked.

  I couldn’t. The scars were non-specific. Electrical burns typically produced one to three millimetre reddish brown circular lesions, according to the Istanbul Protocol, and Li’s scars did not fit this description.

  The lawyer responded with a gruesome image of a disfigured face covered with crusted, blackened areas of skin. “Sorry!” he wrote. “But I Googled ‘electric baton injuries’ and discovered this. It doesn’t resemble the red dots you said were typical. Perhaps such injuries can have a different appearance than what’s described in the Istanbul Protocol?”

  The image appeared to show an acute injury, not scarring, I replied. I was happy to cite a medical source that described alternate scarring patterns from electrocution injury, but I wasn’t aware of any beyond the Istanbul Protocol. Google Images didn’t count.

  “Sorry to be a pest,” Thomas’s next email began. He pushed for stronger wording in my report. I knew he was simply doing his job. But so was I, and I wouldn’t budge. I was limited to the findings from a physical exam and the evidence in the medical literature. I might be the patient’s advocate, but no matter how strongly I might want Li to win his case, I wasn’t the adjudicator.

  Li began every visit by recounting the story of the first time he was sexually assaulted in the camp.

  “He already told us this,” the interpreter said to me during the third or fourth retelling.

  It felt heartless to interrupt, but it wasn’t the best use of our visits, either. I reminded him that we’d documented his experiences in the medical legal report for his hearing. I acknowledged that terrible things had happened to him. I assured him that I’d put in a referral to VAST for counselling. I redirected him to his current day-to-day life.

  “How’s your sleep, Li?”

  “Awake all night, every night. Only sleep during day.”

  “What do you do at night?” I guessed that he was on the Internet, a common preoccupation among my traumatized patients.

  I was wrong. He sat in a chair from sunset to sunrise, facing the door, waiting for something to happen to him. He described how the night before, he wanted to pull the blinds against the harsh glow of the streetlights. Convinced that there were snipers outside, he had to screw up his courage and sidle up to the window, hugging the wall, and quickly yank down the shades before diving for the floor.

  Li had other symptoms of post-traumatic stress disorder, such as nightmares and fearful avoidance of men in uniform, and I started him on sertraline. With counselling, medication, and support from his lawyer and me, he slowly improved over the next months. He was extremely grateful for this.

  “For everything Canada has done for me, I wish to donate my corneas,” he began one visit.

  I was caught by surprise. This was a complete departure from our usual conversation, which centred on his mental health and upcoming legal hearing.

  “Please arrange this!” he pressed.

  I knew little about organ and tissue donation, beyond signing up when one got a driver’s license. “Let’s wait for the results of your hearing,” I suggested. “If your refugee claim is successful, I’ll get the information on cornea donation for you.”

  “I don’t want to wait! Even if I go back to China, I wish to donate my corneas to Canadian children,” he continued, through the interpreter. “How would I arrange to transport my corneas back to Canada?”

  Suddenly I had an unsettling thought. Surely he wasn’t suggesting that he donate his corneas now, while he was alive? The strange nature of his request and his insistence on following it through raised red flags for me. I wondered if this were a psychotic feature related to his PTSD. China had been accused of trafficking organs harvested from Falun Gong practitioners. Perhaps his trauma history was related to this request.

  “I wish to donate them to blind children!” he said urgently. “I am so grateful to Canada for everyone’s kindness. It is the only thing I can think of to give back.”

  I had to clarify, and I couldn’t think of an indirect way to do so. “Li,” I said carefully. “Do you mean that you wish to donate your corneas now? Or after your death?”

  He and the interpreter stared at me, and there was an incredulous pause. Li looked so perturbed by my question that I felt embarrassed that I’d asked it. “When I’m dead, of course!”

  He won his claim. He obtained a work permit and provincial health insurance. His PTSD symptoms faded rapidly. I arranged to transfer him to a community family physician. He never brought up cornea donation again.

  21

  “THEY TOOK EVERYTHING ELSE FROM me,” Junah told me one afternoon in February. “My son, my home, my country. The only thing they couldn’t take was my religion.” It was her one comfort. I asked if she believed in life after this one. She did. “Imagine meeting the one who created you,” she marvelled. “He’ll ask if you believed faithfully, and he will judge.” Implicit in her faith was the conviction that those who had wronged her family would face divine justice.

  The Haddads were Muslim, but they didn’t attend a mosque. They avoided places where other Iraqis might congregate. They were intent on embracing Canadian life; in shaking off their past, their attachment to religious customs loosened as well. They prayed, though, and observed Ramadan.

  I routinely ask patients about religion. It is relevant to health in many ways: Muslims may fast during Ramadan; the Baha’í are typically vegetarian; Christians are less likely to terminate an unplanned pregnancy. Religion can offer community and a framework to understand suffering. I was cautious about how I asked, aware that many of my patients became refugees after someone in authority enquired about their religion.

  I had increasing numbers of patients from Iraq, Iran, and Syria, and I wanted to brush up on my knowledge of the history of the Middle East. It became my bedtime reading. I was reading up on Saddam Hussein one night when I came across a video, footage of the purge of the Ba'ath Party in 1968, narrated by Christopher Hitchens. A young Saddam lounged on the stage, puffing casually on a cigar, as terrified party members were escorted out of the assembly to their executions. I thought of Junah’s steadfast belief in justice in the next life, and I understood her position. How could that kind of evil go unpunished?

  That night I dreamed that I was caught in crossfire in Baghdad. I woke before dawn, exhausted. I wasn’t consciously preoccupied with my patients’ stories of trauma outside of clinic hours, but my dreams hadn’t been peaceful for years. I had nightmares of torture, fleeing my home, being sent to a work camp. When the scenes weren’t directly lifted from patient stories, they still revolved around death: finding my cat’s lifeless body, my son drowning, a co-worker being assassinated. The images were second-hand, I protested, frustrated when they would cling to me for hours after waking. They were just faint impressions of what the actual horror must have been like for my patients. They were only dreams.

  Junah’s comments about judgement in the afterlife prompted me to revisit my own beliefs on the subject. I delved into the history, theology, and literature around the Christian concept of hell. I resisted the idea of eternal conscious torment for unbelievers. But how could an afterlife without punishment be just? It was fascinating but unsettling study. Part of me thought that devoting so many hours of this life to contemplating the details of a possible next existence couldn’t be right.

  Driving into town with my s
ix-year-old to run errands on a Saturday afternoon in May, I was distracted from my ruminations about divine judgement by the never-ending stream of tangential questions from the back seat. “Why do Chinese people use Chinese writing?” Leif asked as we passed through Vancouver’s Chinatown. “Why would they use something so hard?”

  Suddenly I had a question of my own. “Leif, do you know what hell is?”

  “No! What is it?” he asked with interest. I was amazed. And relieved. I pointed out a giant neon rickshaw sign to divert him from pressing for an answer.

  Later that night I emailed my sisters: “How old were you when you learned what hell was?”

  One was five, one couldn’t remember, one didn’t reply. “How about you?” asked the one who couldn’t remember.

  “Six months,” I said. Not really. But it was before I could swim, or ride a bike. Four, I think.

  My childhood revolved around the New Westminster Christian Reformed Church. Grandparents, classmates, and neighbours were all part of the same Dutch immigrant community. John Knox Christian School was directly across the street from the church, on 13th Avenue. We lived three blocks away, my grandparents four. On Saturdays, my younger sister and I rode our bikes through the back alleys of north Burnaby with our school friends, collecting walnuts and exploring vacant lots. The next morning, we’d rejoin those same friends at church. I was wrapped in layers of community, snug and safe. I would recreate this community for my own children, if I could bring it back.

  When I was six, my parents gave us Psalter Hymnals for Sinterklaas, the Dutch gift-giving celebration on December 5. A few years later we memorized the Heidelberg Catechism from the back of the book. It began: “What is your only comfort in life and in death?” I rattled off the answer, no pauses for the commas: “That I am not my own but belong body and soul both in life and in death to my faithful Saviour Jesus Christ.” Every Sunday night we’d recite a portion to my parents and be rewarded with a sticker.

  As a child, I loved the Christian Reformed community. I was more ambivalent about God Himself. I had a clear picture of Him in my mind: Caucasian, short and stocky, clean-shaven with black wavy hair, slumped on a throne with his chin in his right hand. It took me decades to sort out where this image came from. It was not my Dad, or the minister. It was an image of King Saul from our children’s Bible, in one of his depressed states, listening to David the shepherd play his harp. You couldn’t ever be sure if the king would be kindly or throw a spear at you in a rage. I’d known since preschool which one I deserved.

  Now, as an adult, I attend St. John’s Vancouver Anglican Church. The service offers excellent teaching, a connected parish community, and rich historical liturgy. The Book of Common Prayer has a prayer for physicians, that they might be granted “wisdom and skill, sympathy and patience” to “cheer, heal and sanctify the sick.” I think it is remarkable that a liturgical book so neatly encapsulates the biopsychosocial-spiritual model of medicine that was taught with such effort when I started my training.

  Sunday mornings were my respite, providing an opportunity for reflection and orientation that grounded me for another week at the refugee clinic. I had moved away from the focus on doctrinal details that characterized my upbringing. I cared about redemption and its practical application. I deeply admired the Jesuits, who combined priesthood with careers such as medicine or education. An article I read about Pope Francis, who is a Jesuit, described him as the rare combination of intellectual, practical, and humble. This was exactly the triad that described all my heroes, and that I strove to apply to my practice of both religion and medicine.

  And so my preoccupation with the doctrine of hell that Junah’s comments had prompted was out of character for me. It wasn’t the only aspect of my spirituality that I struggled with. It seemed clear that God couldn’t be trusted for personal safety. When my four-year-old was afraid in the night and I was about to reassure her of God’s constant nearness and protection, just as I’d been comforted as a child, I hesitated, thinking of patients who’d depended on that same protection with disastrous results. I analyzed the hymns we sang in church. References to troubles and trusting seemed absurd when I considered the songs were mostly written by Englishmen during times of peace. When the Old Testament story of God ordering the slaughter of the babies of a newly conquered city was explained in a sermon, the theological justification angered me. Violence toward children wasn’t the abstraction it had been for me a decade ago. My patients’ experiences became the standard by which I measured everything. If a Christian concept couldn’t be applied to someone who had been raped, been tortured, or watched their children die, I rejected it.

  It wasn’t until a psychologist joined our clinic that I learned that years of empathizing with stories of trauma can result in a disruption of the physician’s own spirituality. Questioning one’s frame of reference is a hallmark of vicarious traumatization, the psychological response of those who work with victims of trauma. It wasn’t unusual for someone in my situation to struggle with despair and hopelessness.

  At a staff meeting, we were offered suggestions to keep well: balance our personal and professional lives; offset a clinical caseload with other replenishing professional involvements; engage in political work for social change; seek out activities that provided hope and optimism. In short: medicine couldn’t be all we did. We knew that. It was why none of the physicians at the clinic worked full-time. We knew we wouldn’t last.

  When my children were baptized, the prayer that the minister said afterward contained a line that perfectly captured how I wished to raise them: “Give them an inquiring and discerning heart, the courage and will to persevere, a spirit to know and love you, and the gift of joy and wonder in all your works.”

  I wanted those qualities, too. The first and last had always come easy for me. I worked at the third. It was the second that had become a challenge: the courage and will to persevere.

  22

  I WAS FOUR MONTHS PREGNANT AND barely managing to conceal it at work. It was June, and I no longer had the option of disguising my midsection with belted cardigans or careful layering. On discovering I had conceived, two months after our loss in December, I had been overwhelmed by the sense that this was grand work, this close involvement with birth, and, briefly, all else looked anemic. What else had the power of that immediate, unmistakable second pink line on the test strip laid on the bathroom counter? It stood for possibility, for the hope of a healthy pregnancy and a perfect newborn and another loved child. One slim line released a cascade of happy plans.

  Pete and I were thrilled that I was pregnant again, at least as much as I could recall with our other three children. It didn’t feel commonplace; my previous experiences—good and bad—made it that much more meaningful. It had been almost five years since Ariana was born. This me, the thirty-six-year-old mother of three, physician to refugees, living in Deep Cove, had never been pregnant. And yet, personal and professional experience with pregnancy loss had primed me to assume nothing. I’m expecting struck me as presumptuous. And so I was not expecting. I was simply pregnant.

  As a resident, with no firsthand experience of pregnancy or parenting, I’d felt like an imposter when I tried to advise or reassure women. Now, after three kids, five pregnancies, and nine years of providing prenatal care, caring for mothers was one of my favourite aspects of my job. I was sympathetic to morning sickness, knew the pain of miscarriage, and never tired of finding the first fetal heartbeat. Still, I wasn’t the expert.

  “You are pregnant,” I told my ten o’clock patient, a Somali woman dressed in vivid blocks of colours, with a long turquoise cloak over lemon-coloured pants. I was wearing my usual navy trousers, navy pumps, and a loose white blouse. Today my wardrobe didn’t feel professional. It felt dull.

  “No,” she said, bright teeth flashing as she shook her head.

  “The nurse checked your urine,” I said. “The pregnancy test is positive.”

  Hani relayed this. The patient
looked amused and said with the same certainty, “No.”

  “Your last menstrual period was six or eight weeks ago,” I said, “and you’re not using anything for family planning. Is that correct?”

  She confirmed this. “But she knows she is not pregnant,” said Hani. “She knows this.”

  “I would like to book you into the prenatal clinic,” I said, “and do some blood tests.”

  Hani conferred with the patient. “She is not pregnant, but she will do those things if it will make you happy.”

  I saw her four weeks later. I thought urinary frequency or breast tenderness or morning sickness might have swayed her. She denied them all. I repeated the pregnancy test. A second pink line immediately showed up on the strip; I was annoyed with myself for allowing her certainty to inject doubt into the diagnosis.

  She smiled as I tried to find a fetal heartbeat for the baby she knew didn’t exist. Her dates weren’t exact; she might be only ten weeks pregnant, or she might be twelve, when the fetal heart was typically audible by Doptone. There was no fetal heart. Most patients needed reassurance in this situation, but she simply pulled up the waistband of her pink and orange skirt and slipped on her shoes. I ordered an ultrasound.

  The results came back a week later: CRL 16 mm. No cardiac activity. Missed abortion.

  Crown rump length measures the distance from the top of the fetal head to the bum. Legs aren’t included because they aren’t present in very early pregnancy, and once they’ve formed, they are typically flexed. A result of 16 mm CRL correlates with an age of eight weeks. By the patient’s menstrual dates, the fetus should have been at least two weeks further along in development.

  I called the patient in.

  “I had my period this morning,” she said. “A heavy one.”

  I tried to explain that the baby had died a few weeks ago, and this was a miscarriage. I was ready to offer support and sympathy, but she didn’t need any.