Friday October the 15th is International Pregnancy and Infant Loss Remembrance Day. Clare Skinner shares a story about loss and asks us to reflect on how we might care for patients and colleagues better. A trigger warning – discussion of miscarriage and pregnancy loss.
I was driving on the motorway when my phone rang.
‘What are you doing tonight?’, my friend, Paul, asked. ‘I’ve got tickets for a gala dinner. Apparently, Michael Marmot is in town.’
‘I’d really like to’, I said, ‘but I’ve got a trial exam this afternoon. After that I’m supposed to be studying.’
‘Come on’, he said. ‘It’ll be fun.’
It didn’t take much. I was easily talked out of another evening of fellowship revision.
‘Alright’, I said. ‘I’ll meet you at the Opera House at seven.’
I drove to the far edge of the city and parked in a dusty paddock, behind a big, ramshackle pile of hospital. I had worked there once, many years before. I was dressed in a skirt and matching jacket – clothes that felt stiff and uncomfortable compared to my usual scrubs. The stockings were scratchy and hot. My colleagues, fellow emergency medicine trainees, were easy to spot. Everyone who works in a hospital knows that a group of doctors wearing suits, carrying briefcases, and nervously milling in the foyer is a sign that specialist exams must be happening soon.
The trial exam ran for just over an hour. We marched around the outpatient clinics to the ring of a bell – there was a ‘patient’ volunteer to assess in each room. We listened to chests, looked into eyes, and tapped on limbs. A well-established medical ritual performed with precision choreography. While we waited for results, we shared rainbow cake and lukewarm tea. The feedback was blunt.
Four weeks out from the fellowship and I was second-guessing everything. My head was heavy. My tongue tripped over eponymous names and obscure clinical signs only relevant during exams. I was going through the motions. I didn’t feel like me.
The second blue line had caught me by surprise. After a busy month of nights covering sick leave, as well as studying on days ‘off’, I had explained away fatigue and nausea as symptoms of over-tiredness. A long-term shift worker, my body had never kept strict time. Despite years of medical training, I had missed the oldest diagnosis in the book. When I stopped to vomit during a bushwalk my partner, Sven, suggested that I test. The line that signalled ‘positive’ was faint and disconnected, but most definitely there. ‘What’s your favourite name?’, he asked.
We tossed around ideas, bemused by the notion of becoming parents. Sophia? Alexander? Lucy? We marvelled at the person we would grow together. What would they be like? Who would they become? ‘Where are we going to live?’ I worried. Our tiny home unit, up several flights of stairs, was not designed for three.
‘We’re going to need a new car’, Sven said. ‘Plus a stroller. And a cot.’
‘What am I going to do about my job?’, I asked. We calculated the due date using an app on my phone. Seven and a half months seemed a long time to wait. Then it clicked.
‘What the fuck am I going to do about my exam?’
With the trial exam behind me, I hit the motorway and raced back to the city. I found Paul, sitting on the Opera House steps. It was a beautiful autumn night. We skipped across the forecourt, stopping to greet colleagues and friends. The health policy crowd were making a night of it – dressed to the nines, sharing canapes, prosecco and chat. Clinicians and academics mingled, their faces shining as they gathered in orbs of light. Above us, seagulls floated on the breeze. Sydney Harbour sparkled in the background. At dinner, Paul and I found ourselves seated with the guest of honour. Over three courses we solved the problems of the world. When we got back to the car, nothing seemed amiss. There were no signs of the break-in. I drove Paul home, warm in the afterglow of a perfect night out.
When I arrived at work the next morning, I noticed my exam case was missing. At first, I assumed it was at the other hospital. Left on the floor or on the end of a bed. I called the emergency department, clinics, then security. Nothing. I felt the loss acutely. I had been rehearsing with my case for weeks. I knew the equipment it contained, and the order in which it was arranged, with intimate detail. I could examine the cranial nerves, from one to twelve, without pausing to look. I knew the location of the pen torch, the tongue depressor, and the cotton wool by muscle memory. My friend, Kate, who had recently become a consultant, offered me her case. ‘I don’t understand why you’re so upset’, she said. ‘It’s just a case full of medical equipment. You can have mine.’
But it wasn’t the same. No matter. The exam was less than a month away. I had to keep going. There was no time to make another one.
When I told my general practitioner that I was pregnant, she was amazing – helpful and very supportive. ‘Keep studying’, she encouraged me, as she measured my blood pressure. ‘Build a good set of notes. This is your big chance.’ She gestured at a framed photo on her desk, three smiling children in school uniform. ‘Believe me, everything gets more complicated from here. Besides’, she said. ‘This a good thing. You’ve been talking about having a baby for years.’
I kept revising with my group as if nothing had changed. Textbooks, journal articles, guidelines, and piles of past papers. The clinical exam, to be staged in Wellington, New Zealand, neatly coincided with my due date. There was no way I would be allowed to board a plane. There was no way I would be able to sit. Regardless, I studied on. I was determined to be well-prepared for next time.
Soon, Sven and I got our heads around the pregnancy. Surprise turned to joy. We counted down the days until the first ultrasound. We’d started telling people the happy news, trying on the parent role for size. Family and friends were thrilled. Teensy clothes arrived in the mail.
When the day finally came, we were excited and curious. The sonographer ushered us into a dark room and squirted gel on a probe. Like magic, my baby appeared on screen. Black, white and grainy grey, with a tiny, flickering heart. The sonographer’s hands felt caring and warm as she skilfully moved her probe around my abdomen. Then she frowned. ‘What are your dates? Bub’s a bit small for 13 weeks.’
‘I might have got it wrong’, I suggested. ‘I was on night shift. I was busy.’ I was preparing for the biggest exam of my life.
It had been a long day. A busy, bed-blocked shift, then a drive across town to meet up with my study group after work. The exam was only a few weeks away. Home at last, I collapsed into bed. Deep in the night, the phone rang. Shrill and urgent, jolting me from sleep. I answered, only half awake. ‘Doctor?’
‘Yes’, I whispered.
‘I have your medical bag’, he said. ‘The contents are valuable. I’m willing to sell it to you for five hundred dollars.’ The man’s voice was gruff and unfamiliar. I was confused, talking with a stranger in the dark. I wanted my case back, desperately. But the last thing I wanted was to get caught up in something dodgy. Especially with a big exam so soon. My thoughts raced. Five hundred was a reasonable deal – the ophthalmoscope, alone, had cost me more. I haggled him down to four hundred. ‘Okay’, I said. ‘Where will I meet you and when?’
‘Tomorrow’, he said. ‘The Town Hall steps at three. Send a text and describe what you’re wearing so I can find you.’ Abruptly, he hung up. I rang the police and we set up a sting.
The detective rang early the next morning. ‘What are you wearing?’, I joked.
We worked through details. ‘We’ll apprehend him inside the station’, she told me. ‘The CCTV is better in there.’ We planned to stay in touch by text message. If he called me again, I’d dial her number on the landline so she could listen in. In a strange turn of events, I’d found myself smack-bang in an episode of The Bill. ‘Do you want to come along?’, asked the detective. ‘You could watch from a distance.’
‘I’d love to’, I said, ‘but I have revision to do.’
At the agreed time, I sent the thief a message. White shirt, blue jeans, pink cap. Twenty minutes later, the detective sent me a photo of my case and a text, ‘You’re nicked!’
A few weeks after the ultrasound, I was at a conference, about to present my trainee research project. Three hundred kilometres from home in a room full of doctors. I’d grown used to twinges and cramps as the pregnancy progressed, but these were different. Sharper and lower. I felt a trickle in my pants. After the talk, I spoke with a colleague. ‘I think I’m having a miscarriage, I told her. ‘Should I go to the emergency department?’
‘Why?’, she asked. ‘You know there’s nothing they can do.’
I called Sven and he booked the next flight. A few hours later, I picked him up at the airport. We cranked the stereo and began the long drive back to Sydney.
The coast road was slow with school holiday traffic. We sang at the top of our voices. The Very Best of Elton John, every word. We stopped at a bakery for lunch. The bleeding got heavier and the cramps stronger. I was glad we were nearly home. ‘I don’t feel good’, I said. We pulled into the service centre. I headed into McDonalds. It was packed. The smell overwhelmed me – greasy burgers, spilt milk, and hot, bored kids. I’d given only passing thought to a birth plan. It went something like this – tell the midwives and obstetricians to do whatever was required to keep me and my baby safe. Alone in a cubicle, I delivered a nugget of macerated pink tissue and an enormous blood clot. Unsure of what to do next, I wrapped my dreams in a thick wad of toilet paper and carefully placed them in the bin. Back at the car, there was nothing to say. The grief was written on my face. In silence, we drove home.
I was a failed mother. A terrible woman. I must have done something wrong. Slowly, I worked out how to tell people. Slowly, I came to believe my baby was gone. I discovered I was not alone.
‘It happened to me.
‘Yep! Me too.’
I had joined a secret club. As a doctor, I had been taught that 1 in 4 pregnancies end in miscarriage. I quoted this statistic to a patient, a trainee, or a medical student, on almost every shift. But I didn’t see it, or feel it, until it happened to me.
I couldn’t open a book for weeks. The exam was four months away and my supervisor was concerned. ‘It’s going to be difficult’, he said. ‘You’ve lost a lot of time. I’m not sure you should sit.’
But one of my favourite consultants took me aside. ‘You can do this’, he said. ‘You’re an excellent clinician. You’re smart and you really care. You’ve been preparing for years. Put your head down and get the fellowship done. Then, if you still want to, you can focus on becoming a mother.’
I poured my heart and soul into creating the perfect clinical examination case. I began with a laptop bag. Filled it with foam, cut to size. I ordered equipment online. Two shiny tuning forks – low and middle C. A box of Neurotips for testing sensation. A red hat pin, all the way from London. Other bits and pieces were found closer to home. A tape measure from my mum’s handbag. A padlock from the shed. A specimen jar filled with hundreds and thousands. An ancient tendon hammer, a hand-me-down from my ex-father-in-law, retrieved from a dusty box. A former physician trainee, I was determined to leave no clinical sign to chance. The local optometrist gave me a miniature Snellen chart, which I attached to a piece of white ribbon exactly sixty centimetres long. I cut a buttoned sleeve from an old, checked shirt. A bottle of hand sanitiser and don’t forget the bubbles.
The morning after the sting, I picked up my stolen case from the police station. Everything was in place – just so. The only evidence of misadventure was a smear of ear wax on a cotton bud.
Eventually, the big day arrived. Exam day. My baby’s due date. My period was more than a week late. I had decided not to test until the exam was over, but I couldn’t stop thinking about it. I had already imagined myself pregnant. Time passed in a blur. Clinical skills in the morning, interviews in the afternoon. A day measured by buzzers and bells. I used almost every piece of equipment in my case examining a series of ‘patients’ that I will never forget. I double, triple, checked my number on the board. It was a huge relief to learn that I had passed. Hugs with friends. Champagne and cheers all round. I shook the president’s hand, put the college pin in my lapel, and smiled for the cameras. That night, at a shiny bar on the Wellington waterfront, we partied like there was no tomorrow. I had discovered the blood during the morning break. Probably just exam nerves, I told myself. Just a late period. Stop thinking about it. When I got home, I rang the obstetrician. Maybe. Maybe not.
Why am I telling you this story?
I don’t dwell on the pregnancies I have lost. The ones described in these paragraphs and the others. I reside firmly in the present with my two living children. Their day-to-day routines. All the lovingly prepared dinners they refuse to eat. The never-ending pile of washing to sort. Stories, singing and snuggles at bedtime. The terrible jokes. The tears and the joy. I only visit my missing babies occasionally. On anniversaries of significant dates. When memories are triggered – like during an ultrasound course at work the other day. When talking with a patient or teaching students about complications of early pregnancy. On awareness-raising days when miscarriage is in the news. I wonder. Would they look like their brother and sister? Which year would they be in at school? Which books would they be reading? Which instrument would they play? Which video games would they like?
When you know where to look, you find missing babies everywhere. In the medical profession they are incredibly common. My own specialty, emergency medicine, has an average duration-of-training of 7.5 years. The average age at attaining fellowship is 37.2 years. Women tend to get their letters slightly later than men. Miscarriages, terminations, failed cycles of in-vitro fertilisation. Difficult choices made and roads not travelled. Babies born too soon. Life partners met too late. There are missing babies everywhere. Most are hidden from view. The scars run long and deep.
As doctors, there is a lot we can do when a woman presents to the emergency department, frightened she may lose her baby. We can relieve pain. We can do a clinical assessment. Make a diagnosis. We can show compassion. Remember that when a woman pees on a stick, she probably imagines a baby, not an embryo or a fetus. The spot of blood she describes to the triage nurse is the first sign of loss. The loss of many firsts – first cuddle, first steps, first day at school. We can explain, educate, and reassure, using simple, caring, and non-judgmental language. We can help women make informed choices and provide appropriate referrals. We can refrain from making unhelpful comments. No references to ‘nature’s way’. No suggestion that ‘you can always try again.’ Cliches make the hurt worse. We can resist the temptation to tell people how to feel. And we can review standard operating procedures to remove every trace of misogyny.
We can change our professional culture. Nurture people. Make parenting easier and make it feel safe. We can create medical employment and training structures that accommodate pregnancy and parenting. We can reconsider advice we give to pregnant people – ‘don’t tell anyone until second trimester in case something goes wrong’. We should encourage them to seek the support and companionship they need at every step along the way. We can learn how to have conversations about pregnancy loss and infertility. We can give people time and space. To grieve and to heal, in whatever form that might take. Of course, not everyone will feel the same. We can understand that some people choose not to have children and support them too. We can lead and participate in research – in laboratory, clinical and social settings. We can advocate and ask for resources to implement improved, patient-centred, models-of-care. We can learn and educate. We can look after people much, much better. I’m telling you this story because we can make a difference.
When I collected my exam case from the police station, I thanked the detective and asked, ‘Why did you go to such lengths to help me?’.
She said, ‘I could tell it was very important to you. It was obviously about much more than a stolen case.’
And it is.
With thanks to colleagues and friends who contributed to this story – the living and the telling.
If this story has triggered difficult emotions for you, please consider contacting the SANDS phone support line on 1300 308 307 or visit their website www.sands.org.au for information and advice.
Dr Clare Skinner is an Emergency Physician in Sydney. Her professional interests include health system re-design, medical education and improving hospital culture. She is on a gazillion committees. In her spare time, she writes stories, plays music, makes bad art, and hangs out with her partner and kids. | @claski |