Kavanah is a Hebrew word which usually translates to “intention” but denotes an intensity and attention to a task, usually prayer, which elevates it from mundane to holy. My work as a family doctor and teacher cries out to be done this way. I try to really hear what patients are telling me and to truly see what they are showing me, but often routine distractions interfere and it becomes a job. Sometimes, however, the truth and beauty of what we do jumps up and slaps me in the face. It’s then that I feel profoundly connected.
The edges of life are often where holiness is found and I love the hierophantic aspect of my work, helping to guide souls into this world and out of it.
At the time, I was working in my clinic where I saw most of my pregnant patients. With me was a first-year resident, Sharon, a woman in possession of shining intellect and great curiosity, as well as gentleness and compassion. With us was my younger cousin, Masha. I remember when she was 15 years old and our family picked her and her family up at the airport when they emigrated from Russia. The chattering magpie child has grown up into a thoughtful young woman, a medical student at the University of Montreal. She was doing an “observership” with me, an unofficial elective to reassure her that clinical medicine is indeed what she wanted to do when she grew up.
In for her prenatal visit came Lucette. This was her third baby and I had taken care of her throughout all three pregnancies. The first baby was breech and she had a caesarian section. The second birth was a triumphant VBAC. Her two sons, a pair of sturdy boys, resembled their father, Chris, a gentle bear of a man, a fireman and hockey player with a bristling red moustache and a self-deprecating humor. He often looked at Lucette with a bemused adoration as if he could not believe he got to marry such a prize.
And a prize she was. Poised, smart and elegant, even in the ninth month of pregnancy. She looked like a fully rigged yacht with the spinnaker out, moving gracefully in the cramped confines of the examining room. She radiated competence and self-assurance. She had seen both Sharon and Masha over the past few weeks. As an ICU nurse, she knew a lot about medical trainees. I was a little surprised but very gratified when she invited both of them to attend her birth. The two of them were also pleased and agreed to try and come.
The next morning Masha and I went to visit my elderly patient on the ward. This sweet little old lady was admitted for pain control following multiple spontaneous fractures, either secondary to osteoporosis or from myeloma. A week earlier she had suffered a massive heart attack. They had stabilized her in the CCU but her heart was basically hanging by a thread, the pain from the fractures was unremitting despite round-the-clock morphine. “I can’t anymore,” She whispered to me in Yiddish, the enormity of her statement making her relapse into her mother tongue. “I need to live until my grandson’s Bar Mitzvah on Saturday, then I want to go.” My eyes fill with tears and my voice choked up. “I’ll try,” I said to her.
I reviewed her case with the cardiologist and we made plans. I spoke to her two daughters, two very different women, not really close in their own relationship but brought together in the bond of their love for their mother. Her husband was reduced to a weeping, childlike state. He did not want to take part in any discussions, leaving all decisions to his daughters. I carefully explained the situation. It bothered me that I didn’t really have a diagnosis for her bone pain. Somehow this whole situation would be easier for me if I knew for sure that she had myeloma: giving morphine and withholding treatments is easier if one has a diagnosis of cancer. I would never, however, put her through the pain and indignity of a bone marrow biopsy. Her long time hematologist was even more hesitant than I am. “Let’s take care of her, not ourselves,” he advised. Masha was with me during these visits and discussions, often standing at the door, not wishing to impose herself on the grieving family. I was very aware of her eyes on me; I was trying to do this right.
Three days passed, the Bar Mitzvah happened. Her grandson came and sang his portion and gave his speech in her hospital room. She was very weak, drifting in and out of consciousness. A few days later she was still alive though barely. “It’s so hard to die,” she whispered to me. Her daughters dissolved in tears.
Friday night, at around 10 p.m., I got a call from the case room. Lucette was there and in good labour. I called both Masha and Sharon, they were both keen to come in.
A few hours later I got a call that Lucette is 6cm dilated, so I rose from my restless sleep and moseyed into the hospital. Lucette and Chris were standing next to the bed, tethered to the monitor, which she needed because of her previous section. They were slow dancing their way through labour. Lucette leaned heavily on Chris’ shoulder moaning softly with each contraction. Sharon and Masha were already there. When I examined Lucette, the cervix was 8cm with bulging membranes.
“Are you ready?” I asked Sharon. Her usual self-assurance was gone. She was both eager and anxious, her eyes shining but her hands shaking a little. I showed her how to break the waters and a clear gush of fluid followed her tentative poke. “It’s my first delivery” Sharon whispered to me. “Oh your first!” Lucette has heard her, “you must do it then, you have to do your first delivery with Perle!”
“It’s my first delivery too” added Masha, “I’ve never seen one before.” Lucette smiled at me, our eyes lock, we all knew our roles here. Lucette and I joined together. We were the teachers, the priestesses, initiating these two young women into the mysteries of birth.
A few minutes later Lucette was ready to push. We all formed a circle around the bed, Chris and Masha each took a leg, Sharon and I were at the perineum, the nurse standing by, next to the baby bed. Gently, working in synchrony, Lucette pushed a little red-headed girl into the world. My hands gently guided Sharon’s through the manoeuvres. Masha’s mouth and eyes formed three perfect circles of astonishment and delight as she witnessed the miraculous emergence of this beautiful child. The room was at first intensely silent and then bursting with joy. Lucette gathered the baby to her breast. Chris was crying. I was so happy. The whole birth was so smooth, so easy, so focused. I went home and fell into bed.
Two hours later I got a call. Groggy, I lifted the phone to learn that my elderly patient had died. I had an unworthy desire to turn over and go back to sleep, but I knew that my duty is to the living. So I hauled myself out of bed and dragged on my clothes. I went to the hospital, paid my last respects and talked it through with the daughters. The last office of the physician is to walk people through this most difficult of transitions. The daughters and the husband thanked me for my care. It was good.
I left, grabbing a coffee in the nursing station, to join my family at synagogue. I thought about how lucky we are as family doctors to have this opportunity, to have birth and death so closely linked, to be there at these important moments of peoples’ lives.
I entered into the glowing golden light of our little Shul and saw my husband, tall and bearded, looking very Old Testament in his Kippah and prayer shawl. My daughters stood beside him like flowering trees. My son, his face serious, his eyes wide with the responsibility of his upcoming Bar Mitzvah was really focusing, not running out to play with his friends as he did such a short time before. Feeling a little grubby, I slipped in between them, and gave myself up to the service. I prayed with Kavanah.