The Problem of Freedom

The rough, shadowed texture of a log fallen across a meandering stream, the scattered sparkles of the water as it murmurs briefly to a rock it passes, the deep, barely moving green of the leafy tunnel that shrouds the gently dancing blue beneath -these are what I know of freedom: permission to imagine, permission to believe… Nothing else –nothing, at least, that matters more… As Voltaire said, Man is free at the moment he wishes to be…

I’m not sure what I’m supposed to envisage when the topic arises as it does sometimes in the office. I’m not sure what I’m supposed to say, or how I’m expected to react. Freedom is a charged word. A troubled word. It so often refers to an imaginary, or a that-which-is-not. It is contextually defined, and so often spiritually embossed. Like Goodness, or Happiness, it is something to which we are expected to aspire, and because we can never assure ourselves that we possess it, the search, like that for the end of the rainbow, is never done.

It is also a partitioned concept, like being freed from a cage that is locked in a closet that is locked in a room that is locked in a house… To escape from one thing is always to be imprisoned in another –the escape from the innermost Russian doll only to be trapped within the next in line. Freedom, I had always thought, is simply where and when you are; it is a frame of mind, not a frame of circumstance. But I’m not so certain anymore…

This problem of freedom surfaced one day in the office, although I didn’t recognize it at first. The more curious of my obstetrical patients often wax philosophical at unexpected moments. I didn’t think Thira was one of those, I have to admit, but pregnancy –especially the first- has a way of changing a person. Opening them up like the petals of a flower in the morning sunshine. And Thira was a flower. A thin, short woman, she was a Greek with smiling eyes, and spoke with an accent that enchanted me each time we met. I think I sometimes asked her questions just to hear her talk.

But occasionally, she felt it was her turn to ask, and one day, midway through her third trimester, when talk of contractions and labour occupied most of our time together, she suddenly turned serious and her iconic smile disappeared for a worried moment. “Doctor,” she said after I had listened to the baby’s heart beat, “What does the baby’s movement mean?”

I was busy entering in my measurements and the heart rate in the chart, so I didn’t even look up. “What do you mean, Thira?”

“Well, she used to be so predictable. She’d kick after I ate dinner and then start rolling around about ten o’clock when I was in bed. Like she sort of knew what I was doing and was signalling me to say hello. Showing off…”

I looked up for a moment from the chart and smiled. “But you said, ‘used to’…”

The worried look resurfaced. “Well, last night she didn’t stop. She just kept rolling and kicking all night. At first I thought maybe it was the way I was lying in bed, but she kept it up no matter what I did. The kicking even got worse when I got up.” She took a deep breath and looked at the floor. “Okay if I ask you a silly question?” I nodded reassuringly. “Well… I keep thinking she feels trapped in there. I mean, it’s a pretty small space and she’s growing… Wouldn’t it be like being trapped in a small elevator when the electricity and the lights go off?”

I’d never actually considered whether a fetus would –or could- feel imprisoned before. My first thought was to wonder whether the baby, rather than feeling trapped, was actually feeling stressed for some reason –an accident with its umbilical cord, for example, or maybe a change in the placental circulation. I molded my facial expression into neutral so as not to alarm her. “Well, I would think that the uterine cavity space and the darkness is all she’s ever known, Thira. She must be used to it by now, don’t you think?”

She shrugged and painted an anxious smile on her lips. “I suppose… But what if she’s panicking because she’s just discovered she’s trapped? That after all this time, she realizes she’s not actually free?”

I said that before we assumed something like that, it would probably make sense to be sure the baby wasn’t telling us it was in trouble. I reassured her as best I could and sent her right over to the hospital for a non-stress test (NST) to assess the baby’s heart rate in response to its environment; its own movements for example would be the equivalent of someone doing exercise and should raise the heart rate briefly. If there was no change in the rate, or worse, a fall in the rate, it would be unusual and unexpected at the very least. It might signify fetal distress.

The NST was fortunately completely reassuring, as was a bedside ultrasound we did to visualize the umbilical cord and the amount of fluid around the baby. Thira still seemed concerned, though. “I still think she was telling me something, doctor.”

I sat down on the bed beside her. “Well, we can’t find anything wrong, so what do you think she is trying to tell you, Thira? What does she want?”

A weary smile appeared from nowhere. “Freedom, doctor. She wants her freedom.”

I was struck by Thira’s use of the word ‘freedom’ all the time. She didn’t appear at all surprised that there didn’t seem to be any problem we could find with the baby: no umbilical cord around its neck, no decreased amniotic fluid around it, no worrisome changes in the NST. And when I once again reassured her about the findings, she responded with another shrug.

“How can any of your tests measure the need for freedom, doctor? I’m sure most prisoners have normal heart rates, normal responses to exercise…” She stopped talking and looked in my eyes for a moment. “It’s only when you look in their eyes you can tell something is missing. Freedom can’t be tested, I don’t think…”

I had to process that for a moment. “But…  But you’re only 34…” I had to look at the chart I was holding. “34 weeks and 4 days pregnant. Your due date isn’t until 40 weeks… Surely your baby is far too young to appreciate such an abstract thing as Freedom.” I was proud of that response; I thought I had her.

Her face wrinkled in curiosity at my explanation. “I can calm my baby down by talking to her. She seems to respond if there’s music in the room… That’s pretty abstract, don’t you think?”

I blinked. I couldn’t think of another response. But I wondered if this was really cause and effect, or maternal attribution.

“When do babies start to think anyway?” she asked and scrutinized my face. Then she paused for a moment. “Only as soon as they’re born –freed?” she continued after she could see I wasn’t able to answer. “And what about the increasing number of studies showing the abstract conceptual abilities of even young babies?” I must have had a blank look. “Have you read that book: The Philosophical Baby, by Alison Gopnik…?” I hadn’t, actually. “There are others, too,” she said, reading my expression.

“But…” I shook my head slowly in -what? Desperation? Frustration? Or maybe in fascination at something about which only a mother could be convinced.

“If babies only a few months old can demonstrate a sense of injustice or fairness in the studies researchers do with them; if they can be seen reacting to things that seem to them to be unusual or unacceptable, then why would it be so hard to believe they could also have a simple concept of Freedom?”

I have to admit that I didn’t have an answer for Thira, although she certainly opened up a few questions that still trouble me -a Pandora’s box. Is the desire for Freedom innate –like curiosity, the desire to learn, or the impetus to find and create Beauty? Is it so abstract that it doesn’t even exist outside the mind as I said at the start? And is it so integral to our existence, that we need to manufacture it when we don’t think it’s there? There is a problem with Freedom I think: knowing what it is… and where. But maybe Robert Frost got it right: ‘You have freedom when you’re easy in your harness.’  Maybe it’s as simple as that.

Forget it?

Memories are tricky things. Sometimes they’re not around when you want them, only to arrive later, when you don’t; sometimes they surround you, pester you, like wasps at a picnic. And other times you can’t find them at all no matter where you look. But the really tricky ones are those that never happened and yet they stand up and wave at you from the crowd as if they’ve known you for years. Sometimes they convince you…

The idea of false memories –or let’s be kind… mistaken memories- is not a new one, but several well-publicized instances recently have brought it to public attention. In the age of social media, of course, the cases are instant hits. Take the hyper-publicized example of Brian Williams, the popular NBC news anchor who claimed he remembered being shot down in a helicopter in Iraq 12 years ago. When this was disputed by veterans at the scene, he was forced to step down from his job. http://www.bbc.com/news/world-us-canada-31220600

Because most of feel we can rely on our own memories, the feeling was that he had obviously lied –perhaps to enhance his own role and bravery in the combat, or because of the notorious ‘fog of war’ –that state of confusion that arises in states of extreme stress and chaos on a battlefield.

So which was it? Fog, or lie? Or maybe post traumatic stress disorder (PTSD)? Well, the matter is more complicated than it might seem on the surface. There has been a lot of work done on ‘false memories’ of late –how and why they form. For example: https://blogs.brown.edu/recoveredmemory/files/2015/05/Loftus_Pickrell_PA_95.pdf  Memories, as one of the psychologists explained, are not like videos recorded on a DVD –the same pictures, the same information each time you play them. They are more like the material on Wikipedia –able to be modified or even changed completely depending on the need or as a result of any new information that might come along. They are, in a word, mutable. Unreliable.

And yet, unconfronted, the memories seem infallible and in most of our experience it seems counterintuitive that they would be otherwise. After all, why have memories if we can’t rely on them? I suppose the simplest explanation is that if we remembered everything that happened throughout the average day –let alone a lifetime- there would be insufficient storage to say the least. Our brains must pick and choose relevance, perhaps adding or subtracting things for efficiency or continuity as information and situations change… It used to be termed ‘retrospective falsification of memory’. Or, as the authors of the above mentioned paper describe it: ‘Relatively modern research on interference theory has focussed primarily on retroactive interference effects. After receipt of new information that is misleading in some ways, people make errors when they report what they saw. The new post-event information often becomes incorporated into the recollection, supplementing or altering it, sometimes in dramatic ways. New information invades us, like a Trojan horse, precisely because we do not detect its influence.’

This type of situation is certainly not unknown in the medicolegal kingdom. In the course of frightening and unexpected events, there is sometimes a variation of perception –especially if the event is associated with injury or seems to be the result of negligence or incompetance. Totally understandable, obviously, and yet there are often variations of what actually occurred that are remembered.

But the issues are not always of putative malfeasance. Sometimes they have a more personal tone.

I hadn’t seen Joanna for several years, the computer said. I have to admit that nothing about her was familiar. I had no record of seeing her for the pregnancy, but apparently I’d delivered her baby so I must have been on call for consultations that day for my colleagues. She’d not come back for a post partum check, so I assumed she had simply gone back to her regular doctor or midwife. And now, six or seven years later, she was sitting in the waiting room staring at the wall. She didn’t look at all happy to be there. The referral letter said she just wished to talk about a problem. Referral letters are not always helpful…

I smiled at her as I crossed the carpet to where she was sitting and extended my hand. The one that reached out to me was sweating, limp, and tentative –as if, given a choice and not witnessed by the others in the room, it would have stayed rooted in her pocket. Joanna was a small woman with short, tightly curled black hair, held in place by a yellow ribbon so tightly wound around her forehead that the skin in the immediate vicinity seemed blotched and ill. I wondered for a moment if that was why she didn’t return my smile –she couldn’t. It only let her frown.

In the office, she sat in the uncomfortable captain’s chair across from me like a post with knots for eyes. They didn’t move, but instead seemed fixated on something half way across the desk. I tried to put her at ease by asking her how she was but was met with a wooden silence; not so much as a splinter moved. I let the silence lie fallow for what seemed an eternity and then, feeling her anger, asked her as gently as I could, why she’d come back to see me after all these years.

The knots on her face moved upwards a few degrees, and the post shivered. “This is not easy for me, doctor. I didn’t want to come, but my family doctor said I should talk about it with you…”

I leaned my forearms on the desk to show I was listening, and asked her what she wanted to talk about.

She sighed and shifted uneasily in her chair. Suddenly the knots became eyes and they stared at me like the barrels of two guns. Her face tightened and her jaw clenched for a moment. “The delivery!”

I waited, but she remained silent. I wasn’t sure what she wanted me to say. I couldn’t remember it at all, although my secretary had been able to get the delivery note I’d dictated. I skimmed through it quickly, but apart from a ten pound baby and a vaginal tear as she apparently pushed it out before I could control it, I could find nothing else. “Was there something about the delivery you wanted to ask me?” I said when it was clear she was waiting for me to comment on it.

Her eyes grew larger and angrier. “The forceps! I told you I didn’t want forceps! My first baby was large and I didn’t need them for her…” She was almost shouting and little strands of saliva escaped with every word. “I told you..! And then because of the forceps, I got that tear in my vagina that took weeks to heal. We couldn’t have sex for almost 2 months!” Suddenly, tears appeared and ran down her cheeks. “I told you I didn’t want you to use forceps! I told you… But you wouldn’t listen. You kept telling me the baby’s heart was too low and she had to be delivered right away.”

I could see her clenching and unclenching her fists as she talked. “My secretary has managed to find the report I dictated on the delivery. I’m sorry I don’t remember more, but let me read it again…”

“I’ll bet you don’t remember it!” she said between clenched teeth. “The nurses told me about you before my midwife consulted you. Apparently you like forceps and are pretty good at it…” She shook her head sadly and looked at her lap for a moment. “But I told you I didn’t want forceps and yet you went ahead and used them on me!”

I pulled up the delivery report and read it carefully. I’d been exceptionally detailed in my dictation that night, so perhaps I had been concerned that the baby’s condition might have warranted it. I’d been called by her midwife in the middle of the night because she had been pushing for three and a half hours without much progress. The head was not coming down the vaginal canal and the baby’s heart rate was beginning to show signs of distress. I had examined her, explained the situation, and then told her the options: continue to push, although I didn’t recommend this because she hadn’t made any progress after all that time, and the baby’s heart rate was beginning to show decelerations indicative of distress; caesarian section; or trial of forceps (a concept meaning if the forceps weren’t successful after a reasonable try, that caesarian section would be the fall-back option.) She hadn’t wanted a Caesarian, so I’d asked the nurse to get the forceps ready –just in case. Then, when the nurse had entered the room with the forceps, Joanna had become angry and said she would not accept forceps for delivery.

There followed a sudden, profound, and prolonged fetal heart rate deceleration and something had to be done to help the baby right away. The situation demanded an immediate judgment call, and that meant the forceps. But just as I was reaching for them, she gave a mighty push and delivered the baby. Unfortunately I’d been unable to control the head on such unexpectedly short notice, so she’d sustained a vaginal tear. It hadn’t been terribly large, and I’d been able repair it without much difficulty. Baby seemed fine, and there were smiles all around.

As I was finishing reading the report, I could hear her voice repeating again and again “Why did you use the forceps, doctor. I told you not to use them…”

I forced a smile. “I didn’t, Joanna. The baby was in trouble and I needed to get her out quickly, but I didn’t get a chance to use them. You pushed her out as I was turning to get them ready.”

“But I heard them! I heard them clanking…”

Forceps are metal and as the two sides are assembled they often make a metallic clanking noise. (They superficially resemble salad tongs, although unlike tongs, they don’t actually squeeze the head in anything like the same way. They fit more like a helmet over the head and guide it down the vaginal canal like a dilating wedge in front.) I shrugged politely. “It was an emergency for the baby. She needed to be delivered right away, so I was probably getting them ready when you had that really strong push.” I chuckled at something and she stared at me. “Sometimes I think that just the threat of using them is as good as using them. Nothing motivates stronger pushing than clanking the forceps!”

First I saw her teeth and then a smile worked its way slowly into the space around them. “But I distinctly remember you putting them on… I think…” Her eyes wandered to the window behind me for a moment. “Can I see your report?”

I smiled as much in relief as at the dissolution of the tension in the room. “Of course.” I punched a couple of keys and the report chugged its way out of the printer. I handed it to her and sat back while she read it. Actually, she must have read it several times, each time shaking her head in steadily diminishing disbelief. Finally she folded it up and put it in her purse. “All this time…” Her eyes sought mine and I could see they had softened from birds of prey, to… the prey itself. “But I remembered it so differently…”

“Would you like me to see if I can get a hold of the nurses reports as well?”

A large, genuine grin spread across her head dividing her eyes from her chin as she shook her head a final time. “I’m so sorry, doctor… All this time…” Suddenly a thought occurred to her. “Tell me one thing, though.” She tore her eyes away mischievously and they flitted briefly about the room. “Were you wearing an earring that night?”

I must admit I blushed at the question and nodded my head. “It was a phase,” I added quietly.

She giggled and reached for my hand. “Well at least my memory didn’t screw everything up…”

A night on call

I got a thank you card the other day; someone had put it in my mailbox at the hospital.  I suppose it was nothing special, but it touched me: a name I didn’t recognize, an enclosed picture of a beautiful baby, and hand-written with unforgettable penmanship a heartfelt thanks that I had helped the couple in their moment of joy and unexpected need. I must have been on call when they came in, and helped out during an episode of fetal distress -terrifying for them but less so for me, because I couldn’t recall the incident…

How blasé we become when crisis is normal. No, not normal, more… expected. Routine. Few things -in obstetrics at least- are without risk at some level. Nothing can be taken for granted: a ‘normal’ labour suddenly becomes abnormal. A baby’s heart is ticking along quite regularly on the monitor, making all the anticipated accelerations as it moves about in the womb, the rate flattening a bit if it is resting or if the mother is given analgesics for pain, maybe dipping down briefly in concert with a contraction as the head is squeezed by the pressure as it descends deeper into the pelvis in the second stage -generally behaving itself- and then, suddenly, it isn’t. The heart rate decelerates and stays down, the room panics, and beepers go off frantically.

It’s three in the morning, but fortunately the obstetrician is onsite in the Call Room of the delivery unit in our hospital. In the quiet blackness of his little room the phone by the bed erupts hysterically. He is torn suddenly from an already fragmented sleep and listens to the anxious voice. He rushes out of his room into what seems to a be an overly bright corridor, his eyes watering in the light. Unlike the room he has just left, things are neither silent nor calm on the ward despite the hour, and he must run through a patina of  worried glances and frowning faces at the main desk.

There is an almost palpable agitation in the delivery room when he arrives. The mother’s eyes are wide with worry, and the father is leaning over her squeezing her hand, feeling helpless and frustrated. The obstetrician immediately slows down at the door and introduces himself with a confident smile -he must not add to their anxiety by appearing too anxious himself. He is told by the nurse that the mother has been pushing for a while; she is exhausted and at the end of her ability to cope. He examines her and quickly discovers that the baby’s head is well descended into the pelvis -it’s deliverable- and there’s no obvious reason for the baby’s distress. The mother might be able to push it out with more time, but she’s already tired, discouraged, and very worried. And anyway there isn’t more time: the heart rate is too low and it’s not improving despite the valiant attempts by the nurses in attendance to manage it by changing the mother’s position from side to side.

An immediate solution is imperative; a decision must be made -and right away. To deliver by Caesarian Section is an option, but practically speaking, even with luck it will take at least ten or fifteen minutes to get her to the OR, anaesthetize her, make the incision and deliver the baby. No, the baby has to be delivered here. And now! The head, although low down in her vagina, is still too high for a vacuum extraction. Forceps are indicated, but she has no epidural -no way to minimize the pain. So the obstetrician immediately calls for a pudendal set (a long needle covered in a protective plastic sheath that can be inserted into the vagina between the baby’s head and the vaginal wall  and then into the sensory nerve) and injects some analgesic solution. He repeats it on the other side, all the while explaining what he is doing and trying to reassure them. She must not panic and move about. And he needs her to cooperate with the delivery. It is a tense moment, and everybody is looking at him. Staring at him… He must stay calm but above all, he must appear calm. Confident. Reassuring to all around him… Much rides on trust.

Then the forceps -the metal instrument that forms a dilating wedge ahead of the baby’s head to facilitate its delivery as the mother pushes. As he applies them, he explains that they do not grasp the head as pliers would; they do not pull the baby forcibly down the vaginal canal; no, rather, they act like a helmet to protect the head from trauma as it negotiates the otherwise tight quarters that the mother had not been able to overcome on her own. The obstetrician needs to keep telling the parents this as they watch nervously from above.

He waits for a contraction, gets the mother to help him by pushing, and gently brings the head down to the opening of the vagina. He does not cut the skin of the perineum -an episiotomy- but removes the forceps as the baby’s head is crowning and the mother pushes it out on her own: a natural delivery almost… The baby cries, the parents cry and the newly-arrived paediatrician smiles. So does the obstetrician; it’s now three-fifteen and if he’s lucky he’ll go back to his room for an hour of  sleep before the next phone call. The next delivery. The next crisis…

No, every night on call is not as tense; deliveries are joyful affairs and he is usually a mere accessory, a facilitator, a shadow flitting in and out of a room -his name acknowledged in the general wash of emotion, but remembered only until he shakes their hands and leaves. He is a temporary part of the process after all; Nature has been doing this without his help since life began.

He is only special sometimes… But that is enough. It’s what keeps me going after all these years.