Are We There Yet?

There are some things you just have to get right -or else. But, or else what..?  Continuing exposure, even to the most egregious injustices risks dulling the senses; eliciting not indignant shouts but shrugs, excuses not action. Accommodation.

There are benefits that accrue to adaptation, of course –if one lives next to a pulp mill, the objectionable odours soon fade into the background; if one lives in a dangerous neighbourhood, one discovers ways of staying out of danger; these are mechanisms for survival. We can grow accustomed to the most outrageous things, we can attempt to normalize the abnormal. And yet…

And yet that which is abnormal to one culture may be the norm in another. But here be dragons –as ancient cartographers used to say about unexplored territories on maps. One has to differentiate between cultural relativism –accepting that there are many ways of being in the world- and injustice or cruelty meted out in the pursuit of a majority-held social belief system. One that has perhaps been practiced by a population for uncounted generations –so long, even, that it is no longer considered aberrant. No longer noticed.

And the territory is heavily mined –to criticize it, or attempt a change, however laudable, can be seen by those affected as ill-informed at best, and intrusive at worst. Let’s face it, for some issues the dissent is over ideology. Political systems. America, for example, has a thing about spreading its own version of participatory democracy and can’t seem to understand the objections to its imposition –by force if necessary. Others, less convinced of the superiority of the American interpretation, resent the interference, attributing other more venal reasons for its meddling. And who is right? It evidently depends on where you live. Truth defines itself.

But some things do seem to transcend culture and are difficult to defend no matter what the historical cultural practices –torture, physical abuse, murder, to name but a few examples. Whether by outside example, domestic protests, or perhaps even token acquiescence to seem compliant, there is some progress in that regard. For example, I was pleased to see that ‘China has drafted its first national law against domestic violence.’ http://www.huffingtonpost.com/2014/11/26/china-domestic-violence_n_6225876.html The drafted legislation ‘creates a formal definition of domestic violence for the first time and streamlines the process of obtaining restraining orders.’ There are several parts of it that could be improved of course; still, it is a start. A recognition that there was a grievous injury in the body politic. A wound that was long overdue for surgery.

The recognition of defects such as domestic abuse, long tolerated in cultural folkways, is perhaps a natural progression as a society develops. But I worry that the legal protection that is put in place may occasionally overshoot its mark and end up as oppressive as the practice it replaces. It requires thoughtful consideration and sober second thought to prevent unintended injustice. Prejudicial enquiry. Discrimination. As my daughter used to keep asking any time she sat in the car: “Are we there yet, daddy?” “Pretty soon,” was the only answer that seemed to satisfy her -if only briefly. But in this case, soon is not at all satisfying.

In the case of domestic violence –sexual, or otherwise- investigation of the alleged abuse must balance the difficulty of the aggrieved partner in coming forward with the information –the danger to her both physically and emotionally, not to mention the social and legal stigma that might ensue- with the right of the accused to be fairly adjudicated and the evidence impartially considered. I recognize that in this type of situation, it is difficult to progress from a ‘He said, she said’ situation to a balanced appraisal of whatever information is available without seeming to impune the word of either party. And I also understand that, no matter the guilty party, reputations of both, and perhaps even standing and subsequent acceptance in the community, might be at stake. Merely acknowledging the need for a remedy does not necessarily create one.

Sexual harassment falls under a similar rubric, but it is a field even more heavily mined. There seems to be an encouraging awareness of the problem nowadays; women are speaking up about it but often only when it has become intolerable. Indeed even our Canadian parliamentarians are not without blemishes in this regard: http://www.cbc.ca/news/politics/harassment-allegations-against-2-liberal-mps-rest-with-secretive-committee-1.2825385

The issues this type of situation illustrates, are in themselves problematic however: http://www.cbc.ca/news/politics/harassment-on-parliament-hill-6-unanswered-questions-1.2826026 There seems to be no easy solution to the fact that it is important that both sides be heard –not condemned out of hand. Allegations are uncomfortable to submit, and often frought with disciplinary actions should they fall prey to power structures. All too often the victims are too frightened of losing their jobs, or of the publicity and possibility of public ridicule to come forward. Hence the appeal of anonymity, or mechanisms for keeping the accusations one step removed from them. Avoiding potentially damaging confrontations.

But while this offers protection for the victim that is unquestionably desirable if the harassment is to be stamped out, it unfairly (perhaps) predjudices the accused. Unless we accept the concept that a person is guilty until proven innocent, then it is incumbent upon whatever authorities are charged with processing the accusation to adopt an equitable appraisal of all the evidence. Hear both sides.

No matter the society, no matter the longstanding traditions, no matter the crime or the accusations, evidence should trump. It is all too easy to form opinions and act on insufficient information, whatever the ideology involved. It is all too easy to assign blame, especially in the field of personal relations.

But I don’t know… I guess in the end, I’m reminded of Claudio in Shakespeare’s Much Ado About Nothing:

Let every eye negotiate for itself

And trust no agent; for beauty is a witch

Against whose charms faith melteth in blood.”

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A Gynaecologic Chapel

I’ve always been fascinated with the Sistine Chapel in Rome –well, in the Vatican City to be more Catholically correct- but perhaps not for all the reasons you might assume. I have to confess –sorry, poor choice of words- I have to admit that I have little interest in the fact that it is in the Apostolic Palace, the official residence of the pope, nor that it takes its name from pope Sixtus IV who restored it in the late fifteenth century. I’m not really a chapel kind of person, I guess, although the idea of a quiet little room lit only by sunbeams trickling through stained glass has a certain cachet don’t you think? An expectation of a day spent in contemplation; an afternoon of civil recidivism…

Turning inward is seldom an option for a gynaecologist, however. Add the obstetrical duties, and our average day is often calibrated in decibels and pap smears. There are few sanctuaries and fewer stained glass windows –unless of course you count the accidents that spill onto the double panes that separate my office from the building just outside that now blocks my view of the ocean… Milk, juice, sticky candies –I’ve seen them come and go. In other words, one might reasonably conclude that there is no place there which I can designate as hallowed, let alone numinous. No place where I can retreat, even for a moment, into my thoughts. No place where memories dance like sunbeams through purple glass, then thicken into the task at hand.

But, one would be wrong. In these winter days of dark and cloud, when the sun is just a memory and the stores insist we must be jolly, everybody needs a chapel –or at the very least, a vestry-designate. A place where, for a nonce, the mind escapes, and remembrances of things past and present collude. I have hidden one in plain sight for years now. And where better to hide something but the ceiling over an examining table? Long ago when the world was younger, I commissioned artwork for the ceiling. I could not afford Michelangelo, but my daughter –then around eight- offered to do it for an ice cream cone. Bargain. I allowed her to choose the theme of course. Alas, she went secular. No finger creating at an eight year old Adam, but she did manage a nice touch with a berobed and bearded figure speaking to the mortals below: a doctor in scrubs announcing to the world ‘Hi. My DAD (her capitals) the DOCTOR’

My patients are delighted; they think it’s for them –a distraction while I shuffle things around- but, to tell the truth, it’s actually for me. A reminder of that time, now long ago, when I requisitioned a painting for my Sistine Chapel. And what the bearded figure is creating, is memories of my little girl. Each time someone notices it, each time someone points upwards in delight and asks me who drew it and when, and each time I answer, I inhabit, if only momentarily, the world of once-upon-a-time. A world of little girl innocence, of games and stories, and questions I could never quite answer to her satisfaction. A time of yellow sunbeams and grass so green it hurt her eyes. And trees so tall she would have to lie on her back to see the tops. And butterflies in colours that would humble stained glass and render it pale. And quiet times when, smiling in my arms, she would fall asleep exhausted.

It is my Sistine ceiling to be sure, but far more valuable. No myth this painting, no allegorical allusions to pretend-events, or intimations of mortality. Just the imaginings of a child who saw her daddy in a special light. The same light, no doubt, that now shines in my eyes when I think of her.

The Size of the Dog

In the hazy light of retrospect I can still see her lying there on the hospital bed scowling at me. She was clutching her baby as if she’d won it in a game in which she’d cheated. In fact, I suppose she had… But I’m getting ahead of myself. Way ahead.

I’d first met Mary a few years before when I was on call at the hospital. She was pregnant for the first time and was not progressing in her labour. A short woman -she was less than 5 feet- with a tall and heavy husband, she looked almost out of place beside him in the room. They both looked at each other as I walked in; clearly a consultation with an obstetrician was not what they had anticipated. They’d been followed throughout the pregnancy by a midwife, and had only come to the hospital under duress. They both desperately wanted a normal delivery and despite the reassurances of their caregiver that she was just being safe, they suspected the worst.

Mary confronted me with her eyes before I could even approach her bed. “I don’t want an epidural,” she said and metaphorically crossed her arms to ward me off.

“Good, ” I said, “because I’m not the anaethesiologist.”

“That’s not what I meant, and you know it…” her face was hard and then suddenly her forehead wrinkled so much I’m surprised she could even see me. “And I don’t want a Caesarian Section either!” Then she seemed to pout. “Babies do better after vaginal birth..!” She thought about it for a moment. “And so do mothers!”

I could hear the exclamation marks from across the room so I put on my best smile and walked towards the bed.  I glanced at the midwife.  “Susan tells me you’ve been contracting now for almost twelve hours at home….”

“Yes, but they weren’t very strong.”  She noticed Susan staring at her. “Well,  I mean they weren’t all that close together…” She glanced at Susan to see if she agreed.  Susan just blinked -a tired kind of boarding up of both her eyes. I think she could have fallen asleep if the room lights had been dimmer.

“And she says you’re still about four centimeters dilated.” Susan nodded, apparently wide awake again.

This seemed to deflate Mary, and she reached over and squeezed her husband’s hand. I could see a tear rolling slowly down one cheek. “Sometimes labour takes a while, doctor. I know I can do it,”  she said, and yet I could hear doubt mixed with fatigue in her voice. But her face was softer now. Gentler. She was not an unkind woman, but disappointment had robbed her of any dignity.

“I suspect you’re absolutely right about that, Mary.” I walked closer to the bed and stood beside her.  “But I think we’re going to have to do something to make those contractions more efficient.” Now that I was near, I could see the size of the baby distending her abdomen. It seemed huge.

Susan smiled at my expression. “I did an ultrasound last week and the estimated weight is over four kilograms.”

I took a slow, deep breath, but carefully preserved my smile for Mary. “It’s not the size of the dog in the fight; it’s the size of the fight in the dog…”

“I don’t…”

“It’s something my father used to say.”

One of Mary’s eyebrows elbowed its way past a brow furrow and for the first time she appeared amused… Well, anyway, not angry at me. “So you think maybe if you can make the contractions stronger..?” It was a question disguised as a clarification, hiding a deep sense of failure.

I tried to warm my expression. “Well, we can try…”

She studied me for a moment, knowing what I really meant. “But it’s an awfully big baby, you mean?”

I nodded slowly. Carefully. “But you know, sometimes the body is full of surprises,” I said, mindful of the pun.  “In medical school we were always taught that the the secret to a successful labour depends on the combination of Power, Passageway, and Passenger.” I hesitated for a moment. “But sometimes, no matter what we want, and no matter what we do, there is no choice…”

“What do you mean?” her husband said, genuinely puzzled. But fearful. His eyes darted between Susan and Mary like little birds looking for a branch.

Mary sighed and squeezed his hand again. “He never guesses the murderer on the Mystery Channel either, doctor.” Her expression softened as she looked up at him; he seemed so worried for her. “The doctor just means if we can make the contractions stronger, they may be able to push the baby out.” She glanced at me to see if she’d got it right. There was a wisp of a smile lurking just out of sight on her face. I think she was actually looking forward to the challenge.

I ordered an intravenous infusion of oxytocin to augment the contractions, but despite that, after another three or four hours of gradually increasing the dose, even with the stronger and more frequent contractions she hadn’t progressed at all.  Sometimes you just have to admit defeat -or at least claim your victory on a different field.

When I walked in to tell her she would require a Caesarian Section, she wasn’t as tearful as I had anticipated. She was tired -exhausted, in fact- but cheerful. “Sometimes the first labour is a dress rehearsal, isn’t it doctor? You work out all the bugs, so when you try it again, you get it right…”

I nodded reassuringly. I had expected tears.

“So I can try for a vaginal birth for my next one, eh?” It was not so much a question as an entreaty.  And when I nodded my approval -Susan had probably told her I was usually in favour of trials of labour after Caesarians- she smiled. “I think my poor uterus was floundering this time. Probably hadn’t even read the instructions…”

And confident of her future triumphs, she chuckled all the way to the OR and presented me with a healthy, screaming eight and a half pound baby through her abdomen. Her smile spread through the OR like a virus. Some things, some people, are just contagious.

*

I never really forgot the incident, and for years I used her positive attitude as an example to others who required an unexpected and unwanted Caesarian. Like that dog my father had been so fond of mentioning, Mary was one of those who seemed to destined to snatch victory from the jaws of defeat. But, as years and patients slipped past with increasing speed, I realized I would probably never see her again. She became another nameless legend. Another in a long line of inspirational examples to be trotted out when the occasion demanded.

And then, one day there she was: the unforgettable short woman with the engaging, toothy smile. A little plumper than I remembered, and with little strands of grey in the weft of her short, brown hair, but Mary, nonetheless. And she seemed happy to see me.

“I finally decided to move on from the dress rehearsal, doctor,” she said, her eyes bright and twinkling, and her words somehow able to emerge intact through a grin that split her face in half. “I’ve always wondered which dog wins that fight…”

I checked the referral letter on the chart. She was only a month from her due date. I blushed inwardly; that accounted for the plumpness, for sure… “So congratulations, Mary,” I said with enthusiasm. “I hope things work out better for you this time.”

“Things worked out just fine last time, too, doctor.”

“Yes they did. Sorry we had to do the Caesarian, but sometimes there is no choice.”

“Unlike this time, I guess.” Her expression changed subtly, and then the smile returned. “I mean I do have a choice, right?”

I put my pen down and sat back in my chair. Her expression had shifted again. “Of course you do, Mary. Your pregnancy has been normal so far; there seems no necessity for a repeat Caesarian…” I stopped when I felt her eyes focussed on my face.

“But I want a Caesarian Section again, doctor.”

I have to admit my mouth fell open, and I became conscious of the need to close it.

“I was so young and naïve in my last pregnancy. So influenced by my friends…” She sighed and tried unsuccessfully to recapture her smile. “I don’t want a repeat of last time. There’s no need; I have nothing to prove.”

I put on my best doctor voice. “It may not turn out like the last time, Mary. Second labours are different. The body learns…” I could see my words bouncing off her cheeks. “I often tell my patients there should be a different name for second labours, so it wouldn’t engender the same expectations as the first.” Her head was still pointing at me, but I could tell her eyes were not listening. “You know, like the Inuit with their twenty-something different expressions for snow…”

“Whatever. I want a repeat Caesarian, doctor. I don’t want to take a chance on the snow.”

I shrugged my well-intentioned-defeat-shrug and told her I’d try to arrange an OR date for around the time she was due. “But,” I cautioned, “You may go into labour before that date -I mean how do we know?” I smiled as I got her to sign the operative consent forms. “And then you have a choice again.”

One eyebrow explored her forehead for a time. “What do you mean?” she said suspiciously.

“I mean that if you do show up in labour, you have a choice to opt for an emergency Caesarian -no one would bat an eye over that. Or… if you were dilating quickly, you could decide to see if the labour progressed. Our threshold for intervention is really quite low for a trial of labour. You wouldn’t have to worry that we’d try to force stronger contractions, or anything…” I suddenly realized it was me that was bargaining this time. Begging.

Her whole body stiffened. “Perhaps you don’t understand, doctor; I’ve already made up my mind. I do not want to go through another labour! I have made my choice.”

It sounded sufficiently litigious that I quickly nodded my understanding. It seemed the only wise thing to do.

*

As things happen, I was on call a few days before the scheduled OR date for her Caesarian. And, of course, she arrived in the Delivery Suite in heavy labour. She’d arrived by ambulance she was so worried and we rushed her into the assessment room to examine her. Her cervix was already almost fully dilated, and her contractions were coming fast and furiously.  I smiled to reassure her and ran out to book her for an emergency Caesarian. A stat section means right away and as luck would have it, the OR had just finished a case and had not yet sent for the next patient. They assured me they’d be ready for us if we wheeled the stretcher to the OR ourselves.

Just as I was hanging up the phone, however, I heard the nurse yelling for me to come, so I sprinted to the assessment room only to find the nurse trying to manage the baby’s head as it emerged through the vaginal opening. I grabbed a pair of gloves and took over the delivery of a large, healthy, crying baby girl. A precipitous labour and delivery. Who could have guessed?

After delivering the placenta, I inspected Mary for the expected trauma, but… nothing! The skin was intact; there was almost no bruising. Nothing to suture. Nothing to do really, except congratulate her on her new little girl.

But instead of a “Thank you so much!” or an “Am I every happy you were on call tonight!” it was a scowl that greeted me. A pair of furious eyes that followed me around the room as I cleaned things up.

“You lied to me, doctor!” she said through tense lips that barely moved. “You said I could have a Caesarian Section -that I didn’t need to go through another labour!”

I was speechless for a moment, and the room fell silent. The two nurses in the little alcove with me turned and stared at her, then thought better of it and left the area. My mouth opened, but no sounds came through it. I felt paralysed.

Suddenly her eyes relaxed and her face dissolved into laughter. It was the Mary of legend returned from the wilderness. “Had you there for a minute, didn’t I? Sometimes there is no choice… Didn’t you once tell me that, doctor?”

 

 

 

 

 

 

Perchance to Dream

There’s something about complexity that I find intimidating; impressive as it may be, I don’t crave the complicated. I don’t even understand it. Of course, that may be part of its fascination for some: a facet of the instinct that leads to worship of that which is mysterious. Unknowable to the uninitiated. The awe of a dark night full of stars.

Perhaps it’s the structural intricacy, or maybe the number of parts and their varying relationship to each to each other that I find confusing, but not compelling. Inexplicable, but not awesome.

I sometimes think that complexity is a necessary first attempt at something –a way we initially endeavor to solve a problem: throw all our resources at it and then cobble together a solution using as many of them as we can. But in time, that jungle of interacting parts usually resolves itself into a skeletal framework that does the same work, but more economically. In a way, it’s like a sentence in which, instead of a subject a verb and an object that succinctly communicate a message, there are a whole host of unnecessary words thrown in -for colour, not clarity.

In short, simplicity -at least in a device- almost always trumps complexity: less to go wrong, simpler to understand and fix, and usually cheaper to produce. Of course those are some of the more important characteristics of equipment that would be useful in less well developed countries. Places with large needs but small budgets and even smaller infrastructures.

If, for example, a machine is clever, but complex, helpful but profligate of energy, it would be of limited use where electricity is sporadic, or non-existent. Or where, after prolonged use, there are no people trained to maintain it, or no accessible spare parts for that matter. And if the parts themselves are so complex and intricate that they don’t lend themselves to innovative adaptations with available local items, the machine is effectively useless: flashy new cars without wheels. Or engines…

Our society thrives on complexity simply because it can. It reveres new technology both because of its utility in solving old problems –often not appreciated as problematic before its inception- and because it can support its necessary underpinnings. And if the infrastructure is not yet in place, there is usually some facility locally extant that is wealthy enough to create it. For a price, of course.

But there are some regions of the world where babies die needlessly. Low birth weight babies, for example. Some are born prematurely, some are disadvantaged in the womb and never grow properly. And among other requirements, what their small size and lean body cannot provide, is warmth. The inside of the uterus where the baby has been developing is warm –it’s the mother’s body temperature. Normally, when mammals are cold, they shiver to produce heat. But, shivering, which is an attempt to warm the body by contracting skeletal muscles, is energy expensive -energy depleting. And these babies in particular have minimal energy stores when they are born. They are thin and have no extra fat to use as fuel. If they become hypothermic, they can die.

One answer, and one known by every new mother, is to cuddle the baby next to her skin –let her own body’s heat warm the baby. But suppose the mother is unable to do this –say she’s hemorrhaging, or convulsing from pregnancy induced hypertension (eclampsia)? And unfortunately, among other problems, these complications are far more common in poor countries with inadequate antenatal care programs –or at least health clinics that are relatively inaccessable to many in isolated rural communities, even if they could afford the care.

So low birth weight infants need warmth; if the mother can’t provide it, they need to be in incubators until they can fend for themselves. But incubators are expensive and energy-intensive. They require a fairly complex infrastructure for both their performance, and their maintenance. The idea may be intuitive, but the ultimate product is complex; it is usually merely a transplantation of a device that is taken for granted in a labyrinthine, infrastructure-laden country, into one whose poorer inhabitants may not have adequate sewage disposal, let alone electricity, even in the larger towns. And conditions are seldom better in the distant rural villages where roads or communication facilities may not allow reception of news of an emergency or access to provide timely help.

What to do? Well, fortunately dire need spawns ingenuity and there are several ingeniously simple devices created that may well help to fill some of these gaps. An article in the BBC News outlines some of the innovations:

http://www.bbc.com/news/business-23817127

I think my favorite is ‘Embrace’, a product envisioned during a class assignment at the Stanford Institute of Design in 2007. It is basically ‘a sleeping bag with a removable heating element’. It only requires 30 minutes to heat it up, and a phase-change material maintains the bag at 37 degrees C. for up to six hours. And ‘More importantly for mothers, it allows for increased contact with their child, unlike traditional incubators. So it also encourages Kangaroo care, a technique practiced on newborn, especially pre-term infants, which promotes skin-to-skin contact to keep the baby warm and facilitate breastfeeding and bonding.’ It costs about $200 the article asserts, and is reusable. Furthermore, ‘Embrace is a non-profit venture. The product is not sold, but is donated to impoverished communities in need.’ And apparently the organization has even set up educational programs to teach the mothers about hypothermia. Wow!

And there was another article in the BBC News talking about yet another innovation by a student names James Roberts; this one won the ₤30,000 2014 James Dyson Award (which, as Wikipedia explains ‘is an international student design award, organised and run by the James Dyson Foundation charitable trust. The contest is open to university level students (or recent graduates) in the fields of product design, industrial design and engineering, who “design something that solves a problem“’.[ ). The design is for an inflatable baby incubator called Mom.

http://www.bbc.com/news/technology-29900968

‘The device is designed to be delivered as flat-packed parts that are assembled at their destination. At its heart is a sheet of plastic containing inflatable transparent panels that are blown up manually and then heated by a ceramic element. This wraps around the interior of the unit to keep a newborn warm. “When it’s opened it won’t collapse in on the child and will maintain its shape,” Mr Roberts stressed. An Arduino computer is used to keep the temperature stable, control humidification, and manage a phototherapy lamp that can be used to treat jaundice, as well as sound an alarm. The electronic components are designed to use as little power as possible and can be run off a car battery for more than 24 hours when mains electricity is not available. The modular design of the kit allows damaged parts to be replaced without compromising the whole unit. And after the child is taken out of the incubator, it can be collapsed and the plastic sheet sterilised so that Mom can be easily transported for re-use elsewhere.’

Impressive!

So, take an ‘old’ design, and simplify it so it can satisfy a need elsewhere. “How far that little candle throws its beams. So shines a good deed in a naughty world.” How prescient, William…

 

The Slow Cooker

Dare I comment on the speculum?

It is a very underrated item, when you think about it – I mean, if you think about it… Uhmm, considering its job and everything… Ask any gynaecologist. Like shoes, one size does not fit all. In fact, continuing the analogy, there are many shapes and designs: long ones, short ones, wide ones, thin ones, metal ones, disposable plastic ones… And of course, uncomfortable ones that seek to transcend all categories.

Some doctors seem to specialize in one type or another, oblivious it would seem, to basic engineering mechanics, acolytes of the school where Function is a slave to Need –unchanged, some would say, from the glory days of Papanicolau where just seeing the cervix was deemed a success. Old habits die hard though, and so the equation is usually solved by asserting that benefits are worth two times more than discomforts. A handy, if unnecessary, deception if only because it is a justification rather than an explanation. A deafness -another barrier which does not encourage compliance except, as with some dentists, in extremis.

But I like to think that I have a specular selection from which I can choose the least uncomfortable member and am quick to point out that I have endeavoured to match Size to Need rather than the first item I happen upon in the drawer.

I long ago abandoned the disposable plastic speculum in favour of their autoclaveable metallic parents largely because of the greater selection of styles to minimize discomfort. True, never having had to endure what for some must be an unwelcome embarrassment, I nevertheless hope I am sensitive to the anticipatory dread that a gynaecological visit must engender. And I am a male; I would have nightmares…

But for all its putative advantages, there is one major downside to metal when compared to plastic: temperature. More specifically, temperature difference. I do not pretend to understand the physics of why they are always cold but personally, I suspect the First Law of Thermodynamics as defined by Wickipedia: The increase in internal energy of a closed system is equal to the heat supplied to the system minus work done by it. Think about it. The speculum is usually closed while it is in the drawer -and I must confess I do not heat my drawers- and of course its not doing any work in there either… An icicle just waiting for an opportunity.

So for years I have depended upon the hot water faucet in the sink to warm up my choice of speculum; unfortunately I am several floors distant from the boiler so running the water is usually interminable and makes us both uncomfortably aware of our respective bladders. No, the tap is not the answer. But I am a gynaecologist, not a plumber.

I used to joke about my inadequacies and I was getting quite good at innovative excuses. Too good: laughter may assuage anxieties and diffuse tensions, but it slowly and inevitably becomes too valuable an excuse to abandon. Especially when no other solution presents itself.

But although I may not be an engineer, nor a thermodynamicist, some of my patients are. Okay, one of them is.

One winter, when pipes were freezing everywhere in the city, a pregnant patient and I were forced to endure a spectacularly long faucet session. It was the beginning of her third pregnancy and I needed to do a Pap smear. Pregnancy, however, does not easily admit of prolonged personal water storage, and so after a few minutes she was becoming visibly agitated with the wait.

“For god’s sake, doctor, why don’t you just use a cold clamp and get on with it?”

I smiled and walked over to the drawer in the examination table and pulled out a speculum. “Here’s why,” I said, letting the ice cold device touch her leg. “And it’s called a speculum, not a clamp…”

“Should be called a specicle,” she said and giggled, careful not to attract the attention of her already disquieted bladder. Then she sat up suddenly and asked me to leave the room while she got dressed again.

After I went into my office and busied myself with paperwork, the roil of tap water suddenly stopped and I could hear doors opening and closing, and bare feet slapping hurriedly along the corridor leading to the waiting room. After a few minutes she reappeared and sat down across from my desk looking dishevelled, but relieved.

“You have to do something about this,” she said, her lips trying valiantly to smile through her blushing cheeks. “It was the same in the last pregnancy…” She considered it for a moment. “No, I think you were actually able to get the thing warm before I had to leave…”

“It was summer then,” I added after riffling around in her chart for a moment. “But you’re right,” I said trying to put on a professional face. “Maybe I should keep a kettle on the boil in there…”

Her eyes actually enlarged when I said that so I shrugged to diffuse the suggestion.

As a result, the large eyes rolled and the barest hint of teeth surfaced for a second. “What we’re aiming for is warmth, doctor. Tepidity. Not tea.”

Tepidity? I rather liked that word and vowed to try to slip it into a conversation some day. “Well, you’re a mechanical engineer aren’t you?” For some reason I had written this beside her name on the chart.

She nodded mischievously, the light from my desk lamp glinting in her now narrowed eyes. “You mean like I could apply the Second Law of Thermodynamics to your speculums?”

“I thought it was The First Law…”

“There’s a First Law?” she said and laughed so hard I thought she might have to leave again.

*

And then, as time passed, I forgot about specifics and reverted to humour to deal with the inevitable delays in warming the instruments. Forgot, that is, until almost a year later when she arrived for the first visit after her baby had arrived.

After the usual peek at the inconsolably crying baby her worried husband was carrying, the somewhat belated congratulations and then apologies for not being on call for the birth, and her assurance that all had gone exceptionally well, she sat back in her seat. Almost smugly, I thought.

I scanned her chart for a moment. “We never did do the…”

“The Pap smear,” she said, interrupting me as if she’d been waiting all along for me to bring up the subject.

Suddenly I remembered. “Do you want to visit the washroom now? Before I turn on the hot water, I mean?”

She shook her head and glanced at her husband. “I’m fine, thank you.” But her face lingered on him when he stayed sitting. The baby was quiet now, so I thought maybe she was just silently congratulating him. “I think Jennifer needs changing. Is it okay if we change her in the examination room, doctor? Now they were both smiling.

“Of course,” I replied. “Just let me know when you’re ready and I’ll come in.”

They disappeared into the other room wheeling the baby carriage with all their supplies, and closed the door. It is a rather thin structure, the door, and I could hear them whispering and giggling; the baby seemed to be sleeping through the procedure. Amazing.

“You can come in now,” she said after a few minutes in a too-loud voice -the voice of a child who has just hidden some cookie crumbs under the table.

I opened the door and saw her husband sitting quietly on the little chair I keep in the room. I could see the baby fast asleep in her stroller and the mother sitting on the edge of the examining table. There wasn’t much room in there at the best of times, and with the husband, the baby and the carriage, it was like being in a crowded elevator.

I smiled at her and headed for the sink to turn on the hot water.

But I had to thread my way past husband and stroller so before I could make it to the sink she said, “You know I was thinking about it after my little problem with that last Pap smear…” I stopped and turned to her. “I think it was the First Law after all…”

It took a moment for it to sink in. “Ahh, you mean the temperature of the speculums.” She nodded. “Well, it was just a guess,” I said modestly, and meaning it.

“So, I thought I’d correct that and actually apply the Second Law.”

“Uhmm…”

“Closed system,” she said and laughed, pointing to the sink.

Her husband leaned back so I could see more of the counter. And there, proud as Punch, was a Slow Cooker -a Crock Pot- plugged in and partially full of water. There was even a speculum in it.

“Water’s probably not at the correct body temperature yet…” she said and smiled. “But it’ll do for now.”

I walked over to the counter and dipped my finger into the water, speechless for a moment. And then it came to me: “Not quite the correct degree of tepidity, you mean?”

I could see her smiling; she knew it was her word. “I mean, I don’t want to see a kettle in here,” she said and settled back on the table.