It’s hard to believe that it’s our last day in Jordan.
After celebrating World Mental Health Day (usually Oct. 10, however, delayed this year) at a five star hotel in the heart of Amman’s business district, walking some of our favourite streets seemed like a good idea.
Little did we know that the apartment-downtown route we were so proud of figuring out, actually amounted to it taking three times as long as it should to walk downtown.
The combination of speaking only a few words of Arabic, our most polished of which is shukraan (plain thank you), and the fact that the locals don’t use street names at all, makes getting directions challenging to say the least. To further complicate things, shmal, Arabic for north, is used by Jordanians to mean left no matter where you are.
Today, after letting the route itself decide our way, we discovered that once you get to Rainbow St., which is a left, a right, a left and another right away from our apartment, Amman’s downtown core is only a left, a right and another left from there.
Ironically, this epiphany only occurred to us after almost a month of it taking half an hour to walk downtown. Not only did we walk this in 40-degree heat, we also braved it in the pouring rain. The worst part? We kept forgetting specific turns, so we usually had to retrace our steps and make sure we didn’t miss the landmarks we had decided were important for us: Africano pet shop, staircase with trash, Housing Bank, cute coffee shop, umbrella alley.
Despite our well-developed system, we still had to ask for directions every time. “You know Hashem Restaurant?” was the ‘answer’ we usually got as intended to reach any spot on the crowded Prince Mohammad St. As it turns out, we had actually passed by that place several times without realizing it. It also just so happens that it’s one of the best places to have falafel in Amman -just saying.
Our enroute anecdotes could go on for many, many lines. We bumped into a guy who took us to a tourist-trap cafe, we had a spices shop owner laugh at us because we were only buying 10 gr. of cinnamon (in the end, he just gave it to us for free), we posed for a photo with local kids at the Roman Amphitheatre who found us ‘interesting’...
We’re definitely going to miss you Amman. We are going to miss your people and their teachings with actions rather than words about hospitality, generosity and looking at the bright side of things.
But, we’ll be back… There are still many stories waiting to be told, and others that require follow-up from us.
On top of that, we still have to find a place where they assure us that their falafel only contains chickpeas with zero flour, so Clea can have it, and we still have to find someone who invites us to try some homemade mansaf, so Valentina can taste it one more time to make sure she really likes it, since even some Jordanians don’t.
So, see you soon Amman!
Our reporting trip to Jordan is the first time I’ve ever covered stories in a language I don’t speak or understand. Pretty much all our interactions are in Arabic.
I am getting really good at reading peoples’ facial expressions and interpreting their verbal queues so that I can react appropriately, but it’s more challenging than it sounds. Despite the fact that Hala is fluent in Arabic and English and translating on the spot whenever she can, misunderstandings often occur due to cultural differences.
One of the stories we’re reporting on is about mental health. Covering it with the depth and detail we’re striving for involves asking sensitive questions and responding compassionately. Sometimes our characters, the ‘sensitive souls’, laugh at times I might expect them to cry based on the English translation of the question Hala is asking in Arabic. Sometimes an answer that I think will be a few words ends up being half an hour long.
Although Valentina and I understand more now than a month ago, there is still something missing. This is partly because of an unnatural delay; it’s harder to connect with your characters when you don’t understand most of what they’re saying in the moment.
I’m listening to the voices I’m hearing carefully, concentrating on how people are speaking, not just what they are saying. I’m listening to the rhythm of their speech, focusing on how the pitch of their voices rises and falls. I’m listening to the music they make.
In journalism school, I remember one of our professors telling us that radio is the most intimate medium. Now, I understand why.
It is 1:50 a.m. at the Queen Alia International Airport in the arrivals hall.
Ahmed, a dark-skinned, middle-aged, stalky man of average height is wearing jeans and a collared shirt. He speaks only a few words of English and is waiting for me with a smile on his face and a large, white sign that reads, ‘Clea Machold’ in black, block capitals.
As we walked to the parking lot, Ahmed started pressing his car remote key anxiously. He forgot where he parked. He laughed as he kept pressing the remote to find the car, which lit up when he pressed the buttons. “Don’t worry, I will find,” he said.
There were cars everywhere, but Ahmed wove his way to the exit and onto the highway in no time. With the windows down, a pleasant breeze swept through his four-door, white sedan. Despite not signaling and driving between lanes, there were no accidents, not even any close calls in fact.
When we arrived at the apartment, Hala and Valentina greeted me excitedly despite being jetlagged and exhausted, having only arrived a few days earlier. Our hugs were viciously interrupted by the screams of two cats in heat that appeared at our front door.
We spent Wednesday exploring the hilly, narrow streets of Amman. Colourful, intricately embroidered, long dresses were on sale in many shops. Honking horns, the imam’s call to prayer and voices speaking Arabic filled the air.
Then, we found our way to a local bookstore. The owner recognized Hala from their last meeting 10 years ago when she lived here. His contagious laughter shook the bookshelves and our spirits. He served us Iraqi tea to celebrate the reunion.
Using Suhad’s (Hala’s mom) hand-drawn map, our next stop was the Al-Husseiny Mosque.
Then, we took a taxi to Bünn Izhaiman, a 122-year-old local coffee shop. On the way, the driver pulled over and ordered a coffee to go. Turns out that coffee’s flavour can be enhanced with coal as Hala translated his words in real-time.
As evening approached, the three of us girls crammed into the back seat of the third taxi that day with five full shopping bags. The ride home was chilly as the sun set over the city. A flashing, red light emanated from the spot where the car beside us was missing its gas cap.
We have been invited to several special occasions in and around Amman.
The first was a bus trip to Ajloun Castle, also known as Qa’lat ar-Rabad, a 12th-century Muslim castle in northwestern Jordan. On the way, we stopped in Jerash, the capital and largest city of Jerash Governorate, 48 kilometres north of Amman, towards Syria.
This journey is one I won’t forget. Here, people are generous and sincere.
So far, the only nuisance is that I’m celiac. This means I can’t eat gluten, and I’m quickly learning that breads and pastries are staples in the Arabic diet.
Another integral part of the traditional culture here just happens to be offering your guests food, and it’s considered rude when it is refused. It’s for this reason that Hala continually finds herself trying to explain why I basically can’t eat anything I’m offered.
The last stop on our way home from Ajloun was a homemade, picnic dinner. Cucumbers were the only dish where I could say, “Ne’am min fadlik,” followed by, “Shukran”. Forty kilometres outside of Amman, a cup of yogurt spilled, completely drenching my left-pant leg.
After two interviews, three cab rides and several phone calls the next day, we were looking forward to a traditional, Arabic wedding in the afternoon.
Since our hostess was running late, she decided to take a shortcut that I wasn’t aware of. Suddenly, we were in the left lane of the highway driving against the clearly painted, pristine white arrows on the pavement.
“Hala, we’re driving the wrong way,” I said. “I know, we’re taking a shortcut,” she said calmly, as if driving the wrong way on the highway was a completely normal occurrence.
Another thing about driving here is the honking. Certain common patterns exist, including double, triple and ultra long beeps, although I haven’t decoded their meaning just yet, other than to signal grievances about someone else’s driving. These honks are usually followed by forceful hand gestures.
We eventually made it to the wedding, recording equipment intact, and ready to celebrate. Valentina and I had never been to an Arabic wedding before.
Then, a huge slice of gluten-rich, strawberry, sponge cake appeared. A short while later, its chocolate counterpart arrived.
Recently, a conversation with an 83-year-old man reminded me that aging citizens feel largely ignored by our society.
“Have you ever noticed that seniors are invisible?” he asked.
As I thought about his question, its truth struck me.
We think others basically see us how we see ourselves. However, there’s a drastic difference. The more we age, the wider the gap becomes between our own sense of self and the world’s. How many of us look in the mirror and think, ‘That’s not me, not the real me, not the person I know.’
This 83-year-old man is a proud physician.
“Now, when people meet me, they bend down and call me ‘dear,’” he said. “They ask, ‘How are we doing?’ Even the correct pronoun has been lost to me, and the singular erased.”
Or, they don’t bend down at all, he continued. “They talk to my children, or my carer. The nurses and doctors I have come to love in the hospital, which is where I spend a lot of my time these days, are the people who sit beside my bed, call me ‘doctor’ and see beyond my wrinkles, white hair and vulnerability,” he said, adding that, “They’re still respectful and attentive.”
Occasionally, I catch myself saying that my mom ‘was’ beautiful, when in fact she still is. Or, that my dad ‘was’ clever and kind; as if the aged become ghosts in their own lives.
Sometimes, when people describe their parents, they use words like ‘naughty’ and ‘silly,’ as though they’re speaking about young children. Similarly, we often say, ‘I love children’ and ‘I love old people,’ denying them their individuality and fitting them into categories.
If we’re lucky, we grow old. Yet, our culture negates old age; we speak of ‘them’ rather than ‘us.’
This 83-year-old man is aging. Nevertheless, he still represents all the selves he has ever been; the stubborn child, the independent young man, the husband in love, the doctor, the father and the grandfather. He characterizes all of us. We all strive to be recognized. We all endeavor to be seen as unique individuals.
Let’s start with how we look at the world by seeing others as we wish to be seen ourselves and making what is invisible visible again.
Founded in 1995, the Ontario Medical Association’s Physician Health Program, or PHP, helps doctors with alcohol and drug addictions.
Dr. Sam Smith, not his real name, as we agreed to protect his identity, started attending the PHP in 2010, because of a marijuana addiction. A practicing family physician now, Smith celebrated six years of abstinence in February.
When he started residency in 2010, Smith was referred to the PHP because of a question on his application for licensure with the College about previous problems with alcohol, or drugs, which he answered ‘yes’ to.
In fact, Smith was given his medical license on the condition that he enroll with the PHP.
“Most people would just answer ‘no,’” he says. “All through medical school I evaded the truth about how much I was using when I was flagged for failing exams. That question about substance use on the residency application gave me a chance for a fresh start by being truthful. I was told by the PHP that it was ‘refreshingly honest’ [because most] people don’t come into recovery until they’re discovered,” says Smith.
“Either they’re caught taking drugs from work, or they’re hung over, or intoxicated, or they get a DUI, or a colleague will call the PHP, or the College, [to] make a complaint.”
Although a proactive process in the end, getting here has been a long journey for Smith.
“In Ontario, the usual [agreement] with the PHP is five years,” says Smith. “For most people, they recommend urine monitoring, seeing an addiction doctor and sometimes a psychiatrist as well. They also generally recommend an in-patient treatment program and attending Caduceus, a group of health-care professionals with addictions.”
Smith says it has been a positive experience. He has a new contract now, after moving to another province, and will be finished mandatory monitoring soon. As with many physicians in recovery, however, he intends to continue his addiction treatment afterwards.
“The overwhelming thing for me in my recovery was someone [who] said, ‘You have to give up control to get back control,’” he says. “Over time, I really learned what that meant, which was that when you’re in active addiction, or even recovering, but still trying to do everything on your own, or do things your own way, it can be really problematic.”
Smith considers the PHP’s support instrumental in his successful recovery.
“It’s been really helpful for me to have the PHP to say, ‘No. This is what we want you to do. We want you to have all these things in place to keep yourself and the public safe in case you relapse,’” he says.
Based on Smith’s experience, one has to buy into the program, by trusting the people who are there to help you.
“For the first time in my life, I had all these different areas of support and fail-safes to protect me from using, [which] really, really helped.”
The statement, “I wish I had cancer,” recently reminded me of the film Still Alice, based on Lisa Genova’s novel, and dementia’s lonely journey.
This is because these are also the words of Dr. Alice Howland (Julianne Moore), a linguistics professor at Columbia University, when her neurologist (Steven Kunken) diagnoses her with early-onset familial Alzheimer’s disease. She celebrates her 50th birthday with her physician husband, John (Alec Baldwin), and their three children. During a lecture, Alice forgets the word “lexicon.” Then, she gets lost on campus while jogging.
As her illness progresses, she becomes unable to deliver focused lectures and subsequently loses her job. Alice gets lost looking for the bathroom in her own house and soils herself. She fails to recognize her youngest daughter, Lydia (Kristen Stewart), after watching her play performance. Later, Alice visits her eldest daughter, Anna (Kate Bosworth), in the hospital to meet her newborn twin grandchildren, but doesn’t recognize her. Anna tests positive for the Alzheimer’s gene. Her unborn twins test negative, as does her brother, Tom (Hunter Parrish), a junior doctor. Lydia declines genetic testing.
Alzheimer’s is not only a disease of the elderly. The younger-, or early-onset type, affects those less than 65 years of age. In fact, up to five per cent of the over five million Americans with Alzheimer’s have the early-onset form, according to the Alzheimer’s Association. That’s about 200,000 Americans. Many are in their 40s and 50s. They may have careers, families, or even be caregivers when Alzheimer’s strikes.
Last week, one of my patients expressed memory concerns. After a series of other tests, I eventually asked him to draw a clock, a common method used to assess baseline cognitive function. When he tried, he realized he couldn’t do it. Then he said, “I wish I had cancer. People wear pink ribbons for you when that happens.”
A moment of realization for both of us, this reminded me how lonely illness is. Losing one’s mind is a journey we largely walk alone. Perhaps it’s because we’re often as afraid as our patients. Rarely do we ask, ‘What is it like?’ Or, ‘How does it feel?’ Questions considered common practice with cancer, diabetes, or heart disease.
Similarities exist between helping people manage mental illness and other chronic medical conditions, such as high blood pressure, or Type 2 diabetes. Nevertheless, psychiatry is different to other medical specialties. One reason for this is that patients’ intentions and progress tend to be less concretely defined. In the case of hypertension for example, reducing one’s blood pressure to 130/80 is a tangible target. In the context of advanced Type 2 diabetes, making lifestyle changes to avoid losing one’s foot is a specific goal.
With diseases like anxiety, depression, bipolar disorder, or schizophrenia, however, treatment is less black and white. Medication often plays a significant role. Nonetheless, as with all drugs there are side effects, and compliance is a common issue. For the most part, it’s a question of helping people maintain their optimal level of functioning, and major improvements are relatively rare in the field of mental health. Assessing suicide risk is another important consideration in psychiatry.
Often, all I do is listen. Most psychiatric patients don’t progress the way ‘getting better’ is traditionally defined and measured. Huge accomplishments are somebody saying, ‘Do you remember suggesting making a list and crossing things off as I got them done? That changed my life.’ Or, someone with a long history of recurrent hospital admissions, because of repeated suicide attempts, who hasn’t been admitted for a year.
Sometimes, it’s as though people find themselves in a fog. Over time, usually after several years in fact, trust and rapport are established. Eventually, there might be an opening in that fog, which we try to seize. “Don’t use your influence until you have it” has been invaluable advice thus far.
A town of about 20,000, Collingwood, Ont. is fairly small. By comparison, Toronto—the closest, large, metropolitan city—has a population of nearly three million.
Community hospitals like Collingwood’s have many advantages. They’re relatively small, which may make them less intimidating. There’s also a sense of community. In fact, small, local hospitals can even feel friendly.
However, unique challenges exist too. One of these is privacy and patient confidentiality. In Toronto, or New York City for example, it’s common to care for people and never see them again. Or, if one’s paths do cross at a later date outside the hospital setting, it’s likely that patients and care providers won’t recognize each other.
With such a small population, it’s different in Collingwood. This makes protecting patients’ privacy and confidentiality that much more challenging in certain situations.
For example, I often run into patients in the community, including at the grocery store, the pharmacy, the gym, or the local coffee shop and we recognize each other. This can make it difficult to separate one’s personal and professional life, because encounters like this commonly happen several times a week, or maybe even more than once a day.
It’s obviously not appropriate to ignore one’s patients in the community. Nor is it proper to blur the professional line and be too friendly.
Nonetheless, despite its challenges, working and living in the same small community is a privilege that’s also rewarding. Perhaps it comes down to striking a balance between being a professional, yet, at the same time, a caring, compassionate human being in the hospital, as well as in one’s community.
The statement “mental illness is like any other illness” has largely become an accepted truth. This implies that mental disorders, like other medical conditions, all have biological origins.
Aside from mental health complications, because of neurological illnesses, medical conditions like Type 2 diabetes do not typically alter one’s core self significantly. However, mental disorders do by occurrences that change one’s thinking, perception and consciousness of the self, others and the world.
Neuroscience advancements have taught us that several mental illnesses develop as a result of underlying biological differences. Yet, many of the behaviors and experiences that form mental disorders’ core presentations still can’t be explained by neurobiology. Even if this changes in the future, it will still be necessary to understand the experiences of people with mental illness psychologically.
Likening mental disorders to medical conditions confines them to an organ, namely the brain, within one’s biology, but fails to recognize their uniqueness in terms of how they affect the self. This can’t be justified based on our current understanding, nor does it adequately serve patients, or the general public.
Equating mental illnesses with medical conditions can be helpful clinically, particularly in the context of acute crises where medication often plays an essential role. This can become problematic later, however, because it often compromises compliance with crucial psychological and social treatments.
The statement “mental illness is like any other medical illness” is, at its best, an over simplification of a complex human problem and, at its worst, harming patients, families and the field of mental health. Instead, this conversation needs to integrate the complexities of human thinking, behaviour and memories, including the ideas of the self and consciousness.
I recently started working at Collingwood General & Marine Hospital’s Community Mental Health Services. There’s no question that this clinic is making a positive difference in the lives of many residents in the area. In fact, one of our top priorities is keeping patients in the community as long as they’re safe. However, the harsh reality that faces seniors without family support who are no longer able to live independently confronted me face to face this afternoon during a visit to a local nursing home.
In Canada, elderly people who can’t live alone have some choices if family support isn’t available. These include retirement homes, nursing homes, also know as long-term care facilities, or hospice care for those who are very ill and nearing the end of life. There are drastic differences, however, depending on whether or not you can afford care that is privately funded. Most of my patients can’t, which means their only option is government funded care. This is the kind of place I visited today and it was heartbreaking.
During the day, there are two registered nurses and four personal support workers at this 95-bed facility, which becomes one nurse and two support workers over night. My first thoughts were, ‘What if there was a fire? How would three workers get 95 seniors, most of whom can’t get themselves out of bed, never mind walk, out safely?’
Most of the rooms are shared, which means there are two to four residents using the same bathroom. Many of these people are incontinent and most of them have walking aids.
I didn’t get the sense that anyone was really making an effort to get to know these seniors, or what they were like premorbidly, either. There were no histories or photo albums by their beds. When I asked about this the nurse said, “We don’t do that here.” She wasn’t concerned about this though and didn’t give me any indication that they might consider it in the future.
There’s also no autonomy. Routine is important, but what if getting up at 7 a.m. and eating breakfast at 8 a.m. were never part of your routine and now, at 80 or 90 years of age, they have to be because that’s the regimented schedule?
All of this made me wonder why we’ve come to accept this and how we justify it? It seems many of our elderly citizens are falling through the cracks and we’re largely letting it happen.
I’ll do my part to keep my patients in the community as long as safely possible. However, when they have to be institutionalized there should be better public options.
I don’t have a practical answer to this problem yet. What I do know is we need to address it now, because we wouldn’t consider these circumstances acceptable for any other age group.
Although there are many exceptional physicians in the world who listen, ‘Doctor knows best, don’t challenge me’ still features prominently in medicine’s culture.
Even if patient safety is on the line, most medical students and residents won’t challenge their senior colleagues. This is because they think their opinion will be ignored, they’ve been warned by people they respect not to, they fear that doing so could damage their career, or they have friends whose jobs have been destroyed by such behavior.
In his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out, Dr. Peter Pronovost, an intensive care physician at Johns Hopkins, discovered that in 90 per cent of serious, harmful patient safety events, at least one team member knew something was wrong but either didn’t say anything, or spoke up and got ignored.
We know that groups do better than expert individuals, yet we don’t get enough training about how to work this way in medical school. We spend countless hours looking at slides under microscopes to improve our individual knowledge, but very little time learning how to work as a team or how to resolve conflict.
Medicine’s culture of intimidation is slowly changing, however, because we’re starting to talk about it. This matters since it’s the first step towards making hospitals safer for patients, as well as constructive learning environments for doctors.
Credit: The Toronto Star
An experimental program at Sunnybrook Health Sciences Centre allows mothers to hold their babies skin-to-skin immediately after a C-section birth.
After two labours that ended in emergency C-sections, Shannon Connors decided her third child was going to have a more natural birth.
The 41-year-old Kingsville, Ont., mother delivered her eldest daughter, Priya, by an emergency caesarean at Toronto’s Mount Sinai Hospital on May 1, 2006.
Priya was born healthy but there was something missing in the experience for Connors.
“I felt this crazy separation. They gave (Priya) to me in the recovery room, but I couldn’t hold her because my arms were frozen,” she says, adding that this happened because she had been over frozen from the epidural.
After Priya’s birth, Connors tried to learn as much as she could about vaginal birth after caesarean section, or VBAC. “I wanted to make different choices. (Priya’s delivery) wasn’t the way I wanted to experience birth.”
When Connors went into labour with Tallulah, her second child, this pregnancy also ended with an emergency C-section on June 13, 2010. “Nobody was talking. Then I realized, ‘She’s not crying,’ ” says Connors, adding that Tallulah swallowed meconium and was born not breathing for two minutes.
“After this experience, we decided a scheduled (caesarean) was the safest option if we (had) another baby,” she says. When Connors was next expecting, her midwife Nicole Romeiko told her about a technique being studied at Sunnybrook Health Sciences Centre that allowed mothers to hold their babies skin-to-skin immediately after a C-section birth while still in the operating room. Leif, born Dec. 10, 2013, was Sunnybrook’s first skin-to-skin caesarean.
Connors is not alone in her early experiences. One in three Canadians are born by C-section, up from 18 per cent 20 years ago, making this Canada’s most common major surgery. Yet, despite this increase, and research stating the importance of mother/child skin-to-skin contact immediately after birth, hospitals have been slow to adopt this method after scheduled C-sections.
However, this is changing. Dr. Jon Barrett, chief of maternal-fetal-medicine at Sunnybrook Health Sciences Centre and the Fred Waks research chair, has performed 20 skin-to-skin births since delivering Connors’ son in 2013. While Barrett acknowledges there are situations — such as after an emergency C-section — when skin-to-skin contact is not appropriate, he is sharing his results and hopes the technique will be adopted across the country.
“The skin-to-skin method brings the process of birth back to caesarean section,” he says. “It feels more intimate, like a normal birth does. When you do a (standard) C-section you lose the birth part, the emotive experience.”
The skin-to-skin method is already the standard of care for planned caesareans in the United States. Memorial Hospital in Rhode Island founded its “Gentle Caesarean Program” in 2009, the first of its kind in the U.S., and performed 144 gentle caesarean, or skin-to-skin C-section births, between 2009 and 2012. According to this hospital’s statistics, complication rates have been similar to, or even lower than, those for standard caesareans.
Generally, C-sections negatively affect early parenting outcomes. They also increase the mother’s risk of infection, hemorrhage, damage to her intestines or bladder and place excess strain on the health-care system.
Research shows that C-section births in Australia and the U.K. have been associated with more dissatisfaction and psychological distress than vaginal births, and between one-quarter and one-third of women suffered acute emotional trauma symptoms.
Charlene Dormady, 28, of Toronto, relates to these mothers. Her son, Logan, was born by an emergency caesarean at Toronto East General Hospital on Dec. 23, 2013.
“I actually didn’t get to see my son for the first nine hours,” says Dormady. “I didn’t get to breastfeed him, hold him, or do any skin-to-skin. I definitely suffered some trauma, as did (Logan) for sure. We weren’t able to bond at all.”
Even after they got home, it took a long time for Dormady to figure out Logan’s sleeping and feeding queues and she still struggles sometimes.
“I did not have the confidence that I could have had in caring for him,” she says. “Once I got home, I felt like I was starting from scratch because (we) didn’t have that time in the hospital. Up until recently, when I worked through it with a therapist, I (had) days where it really (affected) me in my ability to parent and be calm.”
The fact that Canada has been slower than other countries to adopt the skin-to-skin method can largely be explained by differences in primary obstetric care, says Barrett.
“In the rest of the world, the midwifery and the medical model are integrated,” he says. “They didn’t develop along these separate paths we’ve (created) in North America. It’s not without paradox that (Sunnybrook’s) first (skin-to-skin C-section) was a midwifery patient.”
Romeiko agrees that midwifery practices differ depending on the country.
“The role we play in an operating room in Canada is quite different from being actively involved in the surgery, let’s say in New Zealand,” she says. “Staffed midwives are expected to perform certain steps, whereas here, at least in Ontario, when it comes to the surgery, my role (is) to observe, and then I’m responsible for the baby.”
Barrett hopes the skin-to-skin caesarean method will give these babies and mothers the benefits already proven for vaginal births.
“Skin-to-skin contact has improved hard health outcomes for the baby and the mother,” he says. “Less jaundice, better bonding, more breastfeeding (and) less hypothermia. Those are undebatable. Yet, one-third of our babies are not getting that.”
This realization prompted Barrett to start working on a skin-to-skin program at Sunnybrook that he hopes will mean fewer mothers and babies miss out on skin-to-skin with each other even when C-sections are necessary.
Caesarean birth is carried out by a physician who delivers the infant and another health-care worker who receives it. Normally, the doctor hands the newborn to the health-care provider because the physician has to stay sterile to stitch up the mother. The baby is taken to be examined, cleaned, tagged, weighed and swaddled.
In a skin-to-skin C-section, instead of turning around and handing the baby off the table, the surgical drape is lifted and the doctor passes the infant underneath to the other health-care worker who places it on the mother’s chest.
“(That) was the best moment in all three birth experiences for sure,” says Connors. “It was completely different than my other two births when my baby was immediately whisked away to the other side of the room.”
Leif stayed skin-to-skin with his mother for the next few days. “I didn’t know that those small changes in the C-section procedure would make such a big difference, but they did,” says Connors. “It felt the way birth is supposed to be, the way I’d always imagined it.”
The additional associated manoeuvres known to be helpful to infants, such as delayed umbilical cord clamping that improves newborn blood flow and breathing, are also important and do not happen during standard caesareans.
“If the baby is up there on the mother’s chest, there’s no reason to quickly clamp and cut the cord and pass (it) off,” says Barrett. “It’s still attached to the mother. There’s no real rush, you just leave the baby alone like nature does.”
Overall, health-care professionals at Sunnybrook have been receptive to the general skin-to-skin C-section principle, although there has been some pushback around the procedure’s terminology and breaking the surgical field.
“The skin-to-skin method was initially called a ‘natural birth caesarean,’” says Barrett. “That’s an oxymoron because it’s not a natural birth.”
He has delivered 20 mothers by the skin-to-skin method. But says some doctors are still unconvinced it makes a difference.
“I don’t know if all my colleagues are completely on board,” says Barrett. “I’ve done it with several, but some (remain) skeptical.”
Physicians’ skepticism is based on concerns around a possible increased risk of infection for mothers.
“There is more chance of your hands touching something nonsterile as you lift the drape,” says Barrett. “Therefore, as soon as we’ve done (the) hand-off we change gloves and gowns before going back to the surgical field.”
Romeiko, who has attended two skin-to-skin C-sections in Canada, as well as several others internationally, thinks it’s also important to differentiate between the two ways this method can be done.
“There may be more risk where the cord is left intact (since) it remains connected and continuously stays on both sides of the surgical field until the placenta is born and the cord is clamped,” says Romeiko. (But), I agree with Dr. Barrett that the risk, if there is one, would be almost negligible,” adding that the Canadian women whose surgeries she attended did not get infections even though the cord was left intact.
The doctor’s mindset also plays a role in the hesitation of some to change a surgical practice that has been done the same way for decades.
“Caesarean is a surgery, whereas natural birth is not,” says Barrett. “The sterility is different.”
Romeiko says that transitioning to the skin-to-skin method has also been difficult for anesthetists because it directly impacts access to the mother’s upper body.
“(It’s) taken some adjustment,” she says. “Usually it’s not a family event to attend a surgery. The mentality is completely different in a birth setting.”
There are resource issues too because the skin-to-skin method requires an additional health-care worker.
“An extra person has to be there to hold the baby on the mother’s chest and make sure it’s safe rather than just wrapping it up and leaving it on the warmer,” says Barrett.
Romeiko agrees that the availability of additional health-care providers is an important aspect of using the skin-to-skin method more widely in Canada.
“There’s one trained staff person missing in the operating room (for) families who don’t have midwives as their primary care providers,” says Romeiko. “There’s no one there to receive the baby, be responsible for (its) well-being, assess (its) transition to breathing, or make sure (it’s) held in a safe way and kept warm in the cold operating room.”
Moreover, C-sections are often done in emergencies when the doctor is worried about the newborn’s condition.
“In those situations, you don’t want the baby on the mother’s chest,” says Barrett. “You want (it) on a resuscitare. There are many C-sections where (skin to skin) is not appropriate. You can’t do it in every caesarean.”
The safety of the skin-to-skin C-section will have to be confirmed in Canada before national policies will change, says Barrett. This is why he is working on a qualitative study that will look at the surgical childbirth experiences of 15 women by comparing their perceptions of the standard method to their skin-to-skin experiences.
“As long as there’s manpower and no concern to baby, this could be, and should be, the standard in suitable cases,” he says. “There’s no reason not to as long as we prove that it’s safe and that the baby has the benefits of skin-to-skin contact, especially if it’s a better experience for the mother.”
Connors is sure Canadian women would prefer this method if they had a choice, although she questions whether they really do.
“I believe any woman would choose this way over a normal caesarean if they (could), but I don’t think they (can) because Dr. Barrett is booked up and he’s the only one doing (skin-to-skin C-sections) right now.”
But it’s only a matter of time before skin-to-skin becomes the standard, as well as a choice for Canadian mothers, says Romeiko.
“A psychological or cultural shift within the obstetric and anesthesia world to promoting a more humane type of birth (is happening),” she says. “It is a surgery. There’s no getting around that. But, it’s not an ordinary surgery (and) there are ways to make it more humane that are still safe.”
Original article can be found here: http://goo.gl/rkfJOo
As the days get longer, and the snow continues to melt, spring seems like it’s finally here. Yet, many of us won’t treat the risks of sun exposure as seriously as we should. This is part of the reason why skin cancer rates have actually risen in the last 20 years, especially among people over 50.
Lax sun safety habits seem to be a combination of an aversion to sunscreen’s greasiness, fashion concerns and a generally blasé attitude about the possibility of getting skin cancer.
However, rising skin cancer rates are mostly because of increased sun exposure. In fact, the sun’s dangerous ultraviolet (UV) rays are responsible for 90 per cent of melanoma cases.
In the 1930s, the chance of getting melanoma was one in 1,500. Now, it’s one in 50. The main reason for this change is that we bare more skin than we used to. Yet, despite greater awareness about melanoma risk, there’s still a lot of resistance to using sunscreen.
Another problem is that many of us don’t know how to put it on properly—in order for sunscreen to work, people need to use a sun protection factor (SPF) of at least 30, and re-apply it every two hours. Moreover, whether it’s using sunscreen, long sleeves, or a hat, because these tend to be unfashionable, we generally refuse them.
Popular culture’s images make us think that bronzed skin is more attractive, which is why many of us are willing to risk greater sun exposure. The vanity aspect also explains tanning salons’ popularity. And, although parents are normally vigilant about using sunscreen on their children, these habits readily disappear when kids are old enough to put it on themselves.
Doctors who don’t promote sunscreen to their patients are another factor. In fact, a 2013 study of U.S. physicians between 1989 and 2010, involving more than 18 billion consults, found that sunscreen was mentioned less than one per cent of the time. Perhaps even more striking is the fact that dermatologists reviewed it with fewer than two per cent of patients.
Interestingly, when discussing the sun’s dangers, warning people about the risk of melanoma seems less effective than appealing to their fear of aging, because most of us don’t think we will be that person who gets skin cancer. Let’s make 2015 different and not ignore literacy about sun safety.
It’s been thirteen days since Germanwings Flight 9525 slammed into the French Alps and killed everyone on board. As the details behind this story develop, alongside the perplexing tragedy, the media repeatedly reports on one part: the co-pilot, Andreas Lubitz’s, mental health.
A jumble of facts, assumptions and speculations, this desperate coverage continues to make statements like:
“New information about Germanwings co-pilot Andreas Lubitz. Prosecutors now saying [he] was undergoing medical treatment.”
“Several newspapers in Germany reporting that Lubitz had been undergoing psychiatric therapy. Not quite a smoking gun, but a whiff of gunpowder in the air if nothing else.”
“The co-pilot in the Germanwings crash reportedly had a history of depression. Andreas Lubitz was even treated at this clinic in Düsseldorf within the past two months. For what we do not know.”
“He once told a girlfriend that the entire world would someday know his name. Lubitz [said] he was in psychiatric treatment and was planning a spectacular gesture.”
“Why on earth was he allowed to fly? Suicide pilot had a long history of depression.”
I think there’s agreement that we need to discuss Lubitz’s mental health since 150 lives were lost and everyone deserves answers. However, sensationalizing stories that intertwine mental health and disaster is damaging. We’ve come a long way in terms of de-stigmatizing mental illness, but this kind of coverage brings us back to square one.
Stigma is the biggest reason people avoid treating mental illness, and attitudes don’t change quickly. One badly reported example by the media drives people away from seeking treatment for illnesses like depression. Public safety is critical, but how many people will be hurt, because of how this story is being covered?
Mental health + 24/7, instantaneous news
Germanwings Flight 9525 is breaking news. However, we’re misinforming the public about the role mental health issues play in the lives of those afflicted with mental illness. Most depressed people don’t hurt others. Nor do they typically plan a “spectacular gesture.”
The truth is we cover mental health badly most of the time. That’s dangerous because it distorts peoples’ understanding of mental health.
Events need to be explained. In this case though, we’re rushing to explain a story we barely know anything about. We don’t know if Lubitz was depressed. What we know is that he suffered depression previously, which isn’t the same thing. In this story for example, we’re using depression as another word for dangerous, which simply isn’t true.
Fear of saying what we don’t know
The known is that Lubitz was treated for depression in 2009. The unknowns are what kind of treatment he was receiving when this plane went down, whether the mental health system’s accountability failed here, and what kind of psychological testing he actually endured as a pilot.
Knowing the answers to these questions would change the context of the few facts we do know. Yet, we generally have a tendency to use small pieces of information to explain way more than we should allow them to.
We don’t diagnose diabetes and heart disease based on incomplete information, nor should we diagnose depression and psychosis before we know the facts.