“I kept telling you,” she said patiently. “I wasn’t pregnant.”
Technically, I’d met the standard of care. I couldn’t think how any other medical course of action could have been justified. And yet, I felt that it was she who had graciously accommodated me. I had made Western medicine look a little ridiculous to both of us.
I was often reminded that I valued the medical component of clinic visits more highly than the patient did. Junah came to see me often, usually regarding paperwork for Layth, sometimes about headaches or fatigue. I didn’t feel that I offered much as her doctor, but I did make her laugh at every visit. When she told me that just seeing my face lifted her spirits, I told her that there was no need for her to come into the exam room, then; I could just hurry by the waiting room, glance at her sitting there, and she could go home. She was delighted by this, either at the joke itself or the fact that a physician would be playful with her.
But Junah did not show up for that morning’s appointment. After lunch I saw her in the waiting room, sitting with Hani. She looked upset. I joined them on the pew.
“She took the bus by herself for the first time,” Hani explained, “but she didn’t know which stop to get off at. So she just rode the bus up and down Broadway. Then she saw me walking back from lunch! She got off the bus and threw her arms around me, crying.”
Navigation was often an issue for patients. Many were unfamiliar with street maps, and map reading was not as intuitive for them as it felt to someone who had been introduced to it in kindergarten. A Nigerian patient told me once, “I understand maps of Africa, with all the countries in different colours, but I’d never seen a city map with lines for roads.”
Due to Vancouver’s high cost of living, most patients resided in the suburbs, and public transportation to the clinic required multiple connections. Most patients couldn’t read English. I’d overheard the Burmese interpreter giving directions to one of my patients: “Get off SkyTrain at King George Station. That’s the one that starts with the letter that looks like this,” sketching the three strokes of the letter K in the air with her forefinger. I was amazed that patients found us at all.
I ushered Junah and Hani into my exam room. “What can I help you with today?”
“Pregnancy test,” said Hani, as Junah tried unsuccessfully not to look jubilant.
It had been eight months since she had told me she wished to conceive. She’d done the bloodwork and taken folic acid supplements. The wait list to see Medical Genetics was one year. She’d refused to hold off until then, and I didn’t blame her. I guessed that no matter what a geneticist advised, Junah would pursue pregnancy.
“What was the first day of your last menstrual period?” I asked.
“It should have been three weeks ago, but it didn’t come. The last one was May 2.”
I took an orange-topped urine specimen container from the cupboard and wrote her initials on the label with a Sharpie. “Follow me to the bathroom,” I said. “Fill the container one third full, put the lid on tightly, and leave it in the cupboard next to the sink.”
The back of the cupboard opened onto the specimen room next door, where I waited. I heard the rustling of undress, a pause while she peed, a flush, the plunk of the specimen container being set on the metal shelf, and a click as the cupboard door swung shut. I opened my door to the cupboard and carefully removed the container. It was full to the brim and intimately warm. Like virtually all urine specimens I collected, the lid was set carefully on top but not screwed onto the container—a pending splash.
I tore open a pregnancy test package and used the soft plastic dropper to add two drops of Junah’s urine to the sample well. I watched as the edge of urine wicked up the test strip, toward the pink stripe. I knew that in Room 146, Junah was praying silently and fervently. Kurt Vonnegut would say she was angling to change the shape of her story, to end things with an upswing, toward good fortune. As her physician, I was alert for potential dangers, and already I could imagine a half dozen that pregnancy could bring.
The urine washed over the test area, immediately producing a second solid pink line. I dropped the test into the trash, one of a dozen tests done that day, disposable slips of news of heartache and relief, joy and dismay, and went to give Junah the results.
“You’re pregnant,” I said. “Congratulations!” I meant it.
“Alhamdulillah,” she said simply. Her prayers had been answered.
I pulled my pregnancy dating wheel from the drawer and matched up the dates. “You are seven weeks pregnant,” I said. “Your due date is February 6.”
I saw her again four weeks later. Every Tuesday afternoon for eight years the nurse and I had run a prenatal clinic for our refugee patients. All our patients, regardless of whether they were an Iraqi psychiatrist or a Somali villager, had the same basic concerns as all Canadians: the baby’s health, their own physical symptoms, and financial resources. Every patient had the same smile spread across their face when I first ran the gelled Doppler probe over the uterus and picked up the steady, rapid drumming of a fetal heart, like hoof beats.
Junah was no different. We listened for a full holy minute, for one hundred forty-two tiny thuds. It was just Junah, Hani, and me; no one said a word. Pregnancy had not lost its power to amaze me. Regular clinical visits were almost always about a problem; the excitement of a pregnancy was a welcome change.
“It sounds good,” I said finally, wiping the gel from her belly with a tissue.
Junah tugged her dress down over her belly and sat up. “If the baby is a boy, we will name him Ahmed,” she said.
“Ahmed,” I said. “I like that.”
“If it is a girl, we will name her after you.”
I was touched, and taken aback. “Thank you!” I said. “I’m honoured!” I loved the idea of a little Iraqi-Canadian girl named Martina being raised somewhere in Surrey.
Junah looked at me expectantly. I wasn’t sure what she was waiting for.
“So?” she prompted, finally. “What is your name?”
“Oh! Martina.” Although I’d introduced myself at our first meeting, she’d never addressed me by my first or even last name. I was simply Doctor.
“Martina,” she said, carefully. It sounded different with an Arabic accent. It sounded perfect.
Junah slid off the exam table and settled in the chair. “As a woman, how do you be strong, but kind and loving and forgiving at the same time?” she asked me through the interpreter. I knew that the joy of this pregnancy wouldn’t cancel out her grief. I knew that having a child after the loss of another one was psychologically complex. She looked at me expectantly; she wanted an answer. And I recognized that this was less a patient asking a question of her doctor, and more a woman asking a question of another woman. I was moved that she would think I had any advice to give her. I knew that my life had not required the strength and forgiveness that hers had asked of her.
As I offered my thoughts, I wondered whether the twenty-five-year-old me would have had anything to say. I doubted it. In fact, I seriously doubted that anyone would have asked my fresh-faced self such a question in residency or early practice.
I’d always looked young, and had received countless remarks about it as a medical student. The comments were made in a marvelling or appreciative way, but as a novice struggling to project confidence and professionalism I didn’t find them helpful.
Looking young became much more tolerable a few years later when I was twenty-eight and being taken for twenty-two. And then I had three children, and I’d been in practice a few years, and comments on my age trailed off. One day a patient said to me, “You must be about my age—from 1974?” I was shocked that he had nailed it. Shortly after, for the first time ever, I asked my hairdresser for a cut that would take a few years off. She gave me bangs.
It was a rare moment when I acknowledged that there might be advantages to not being or looking twenty-two. If my aging suggested to patients that I had lived even a little, and had l
earned something from it, I was grateful for it.
Grief is not weakness, I told Junah. Strength is compatible with tenderness. She could mourn Sami’s death and honour his memory while living purposefully to care for Layth, Nadia, and the new baby. Junah listened intently to my responses. Little did she know that I absorbed her words about faith and optimism with a similar keen interest. Why was I so cautious and fearful about my own pregnancy when Junah embraced hers, serene despite intimate knowledge of the blows life could deal?
If she was expecting, I decided, then so was I.
23
I HAD A MORNING OF PEDIATRIC assessments, with patients ranging from an infant to sixteen-year-old Layth. The father of my first patient told me proudly how he’d weaned his three-year-old son since his last visit with me: “I showed him a picture of a gorilla nursing her baby and I told him, ‘If you keep this up, this is what your mom will turn into.’”
Before I could comment, he went on: “I heard that in Canada, parents bring their kids to the zoo before the kids are old enough to go by themselves. Is that true?”
“Yes.” Every North American zoo I’d ever visited had been packed with strollers, and I’d never thought to question whether it was appropriate.
He considered this, impressed. “In Canada, parents serve their kids,” he observed. “Where I come from, kids serve their parents.”
I found this commentary interesting, but I also had a developmental checklist to get through. I scanned for the questions that were relevant. Bike helmets and car seat safety were not; the family lived in a tiny apartment and relied on public transit.
“Can Johro use a sentence with five or more words?” I asked, trying to steer the conversation back to his son’s assessment.
“Yes,” said the father. And then, chattily, “When I take him to the park, I’ve noticed that parents here don’t beat their children.”
The visit ended with me briefing him on the legalities of corporal punishment in Canada. The breadth of what fell under the auspices of family medicine seemed to increase daily. I did not question, though, whether the discussion was necessary.
When I returned to the waiting room, Layth was standing with his arms folded over his chest, staring at the door he knew I’d come through, waiting impatiently to be called. When he saw me, he grabbed the yellow backpack at his feet and charged for the exam room. Yusef and Hani followed unhurriedly.
“He’s annoyed that he’s missing class for a doctor’s appointment,” Hani told me as we headed down the hall. I considered this excellent news.
“Tell me about school!” I prompted Layth, once we were settled in the exam room.
“I like it.” He had been attending Grade 10 at the public high school two blocks from his home, with a modified course schedule and an aide, for the past seven months.
Yusef pulled his phone from his pocket, swiped and tapped, and passed it to me. It was a video clip of what appeared to be a high school musical production of Charlie and the Chocolate Factory. “I didn’t understand it,” he said, pointing out Layth in an Oompa Loompa costume, “but I Ioved it.”
Since my initial assessment, Layth had had a head CT, followed by an MRI for further detail. The report described the brain structures in crisp detail: Thin corpus callosum. Decreased volume of cerebral white matter. Sulcal enlargement.
The abnormalities didn’t point definitively to a diagnosis. The images might be clear, exposing the anatomy of the brain in wondrous black and white detail, but the findings were nonspecific. Layth’s condition remained a mystery. The pediatrician wrote in her consult letter that she agreed that he likely had a genetic syndrome, one rare enough that she didn’t recognize it. Other than treatment for his chronic constipation, she had little to offer. The wait for Medical Genetics was over a year long.
Medicine might have come up short, but his teachers and classmates had transformed Layth’s life. He was the calmest and most content he’d ever been, Yusef reported. He worked well with his aide, played soccer, and was learning English more quickly than his parents. The only concern was that some of his new vocabulary dismayed his parents with its vulgar bent. And he had started smoking cigarettes with his new friends.
Layth wasn’t my first patient with a disability to thrive in Canada. A visually impaired Iranian man was guided into the office at his first visit by his two little daughters, each one holding a hand. He’d never seen either of their faces.
He played goalball, a Paralympic sport similar to indoor soccer, for the visually impaired. The ball had bells inside, the lines were cords taped to the floor and the goal was nine metres wide. Spectators had to maintain complete silence so that the players could hear the ball. When he first described the sport, I wondered if was teasing me.
Within weeks of arrival in Canada, he was learning Braille for the first time and attending ESL classes. The lessons weren’t coordinated, though. He described spelling out English words in Braille whose meaning he didn’t yet know. In English class, he could hear the words but could not read the board or handouts. I was dismayed at the impracticality of this, but he laughed. He could only see opportunity.
Filling out a form regarding his disability one afternoon, I paused when I arrived at the question, Does the patient require an assistive animal? He was Muslim, and I was confident that he would want nothing to do with a dog. My policy was not to make assumptions, though, but to let the patient decide. I described the concept of a seeing-eye dog to the patient and his wife. Initially confused, huge smiles spread over their faces when they realized what I was suggesting.
“Doctor,” interrupted his wife incredulously, “you are saying he could have a dog, attached to a rope, leading him around the city?” When I affirmed that this was, in essence, the idea, they laughed so hard that I blushed.
“Thank you,” he finally gasped. “But no.”
It was difficult for some patients to suddenly be presented with a solution to a chronic condition. An Afghani woman, deaf from birth and using a self-styled sign language with her family, learned from the ear, nose, and throat specialist that she was a candidate for a cochlear implant. She refused it, to her family’s dismay. Her husband and teen daughter brought her to see me, hoping I could convince her to pursue the treatment.
The visit quickly erupted into shouting. “What if it makes my migraines worse? What if I’m dizzy?” signed the patient, flicking her hair back angrily.
“You’re so selfish!” shouted her husband, his hands signing furiously.
“You only think of yourself!” yelled the daughter. Then, just as I was about to rein them in, she pleaded: “We just want to hear your voice!”
Not everyone’s life improved in the new country. “She was fine collecting firewood at the camp,” one patient told me about his wife. “No one bothered us. Life is too complicated for her here.”
His wife had an IQ of 70. When they left the refugee camp in Nepal for an apartment in Surrey, she struggled with simple tasks, such as using the stove and unlocking the front door. There were questions about her ability to care for her children.
“She was better off in the jungle,” he said.
I silently agreed. It seemed a foregone conclusion that refugees with disabilities would benefit greatly from the Canadian system. Most did. We offered universal healthcare, world-class medical treatment, inclusive public education, and disability benefits. But not every patient viewed their condition as an impairment that needed to be corrected or supported. Some simply wanted to live as they were, in peace.
24
“PLEASE TAKE OFF ALL YOUR clothes,” I said, miming the removal of my own shirt and pants, “and put on this gown.” It was Tuesday afternoon, prenatal clinic, and the schedule was fully booked with a diverse set of patients. The first, a twenty-two-year-old Eritrean woman, was here for her physical exam.
The Tigrinya interpreter repeated my instructions, the patient smiled and nodded, and I pulled the soft blue curtain between us. I heard brief r
ustling; then all was still. I looked around the curtain to see her lying on the table, fully clothed.
“Please remove all your clothes,” I reiterated, again supplementing with gestures. “I need you to take off your pants, shirt, bra, and underwear. Everything.” She made an exclamation of understanding, and I turned back to my desk to prepare the requisitions.
When I next pulled back the curtain, the patient was lying full-length on the table, pants on, sweater half over her head, with her bra bunched around her throat. This time I addressed the interpreter directly. “She didn’t understand. She’s still dressed. All of her clothes must come off.”
Shortly thereafter I heard a burst of activity behind the curtain. I looked in to see the patient standing on the table. My six-foot, pregnant patient was briskly disrobing while standing on a slender vinyl-covered exam table forty inches above the floor. I decided it was safer not to intervene and went back to assembling the speculum and swabs. A moment later she called out that she was ready.
And she was—lying on the table naked with the gown rolled up into a ball and tucked beneath her head.
The next patient, a Myanmar woman, was in for her first prenatal visit. This was her seventh pregnancy. I teased apart her obstetrical history through the interpreter. Two children were stillborn. It felt unholy to document the details in columns on a standardized form, but she held steady, and it seemed to her to be a matter of fact. My medical textbooks referred to catastrophic obstetrical events. Catastrophe comes from the Greek, sudden turn—a reversal of what is expected. It was my job to be vigilant, scanning the horizon for anything foreboding. I wanted the patient to enjoy this pregnancy, oblivious to threats.
Initial screening at the clinic had picked up microcytic anemia in her and her husband; further testing confirmed thalassemia trait in both. They were asymptomatic carriers. The only concern was that a future child might inherit the faulty gene from both parents, causing significant disease. I gave the clearest explanation I could, but the interpreter was confused, struggling for the Karen words, and my message appeared in the end to be relayed simply as, You have bad blood.
Your Heart is the Size of Your Fist Page 12