"The patient leaned forward, squinting, trying to decipher the gray and black pixels that meant she was now a mother."
“See the little flicker?” the doctor asked, as she tilted the ultrasound screen and pointed to the tiny movement. The patient leaned forward, squinting, trying to decipher the gray and black pixels that meant she was now a mother. “That’s the heartbeat,” her doctor explained. “Right there,” she pointed again, this time zooming in even further. The patient nodded as she tried to contain her excitement. She smiled with one of those tight-lipped grins as her eyes widened, as if joy was actually bursting out of her. Her husband chuckled at her wild expression and squeezed her hand. “It’s okay,” her doctor said. “Be excited! This is exciting!” And with that word of permission, the expecting mother squealed, just a little, and calmed herself again. “It’s our first, you know, and my sister just had a girl and I wanted our kids to be able to grow up together and we just didn’t know if it would happen this fast, and,” she paused to catch her breath. “Sorry, I just can’t believe we get to start buying baby stuff!”
I looked at the screen again, at the little flicker of light, at the little piece of white against black that would someday have a lot of “baby stuff” foisted upon it. It was one of the earliest pregnancies I had seen on ultrasound – in fact, I had only seen one other scan done at the same gestational age. It was striking how identical this scan was to the first one I had seen, months earlier. The screen had looked exactly the same, with the crown-rump length of the tiny embryo measuring the same, with the same shape of black fluid around white tissue. I thought back to that day, to the tiny portable ultrasound screen so far from home. Instead of an antiseptic outpatient OB/GYN clinic in temperate California, the first scan had been done on the dirt floor of a little hut in Central America.
"It is common for women in the Ngobe communities to have as many as ten kids; oftentimes they start having children when they are teenagers themselves."
It was a typical clinic day in rural Panama – humid, muddy, with lines of patients waiting to be seen. Working over the summer with the non-profit organization Floating Doctors, I saw many pregnant women come to clinic for prenatal care. Traveling to indigenous island communities, where most patients have no other access to health care, we would set up makeshift clinics and see as many patients as possible. It is common for women in the Ngobe communities to have as many as ten kids; oftentimes they start having children when they are teenagers themselves. Unsurprisingly, there was a lot of prenatal ultrasound scanning to be done. When I saw this particular patient, whose ultrasound was done so early in the pregnancy, the crown-rump length measured the same as the patient I would see months later at home. This woman was 32 and had five children. Her youngest, a two-year-old girl, leaned on her mother’s chest as I scanned, taking a pause in her whining to stare at the screen. She didn’t understand what it was, but her mother squeezed her excitedly anyway as I pointed at the little flicker, the unmistakable heartbeat. Even though they already had a big family, even though it was miserably sweaty sitting on the floor in our little ultrasound hut, and even though the toddler was getting fussy, this woman had the unmistakable grin of sheer excitement.
Talking to the pregnant women in Panama, either during the scan or translating during the physician checkup, I imagined the lives that these babies would have. It was an easy thing to think about, seeing so many children running around and playing as their parents waited in line. The kids were a handful to organize; it was no easy feat keeping them far enough away from the clinic to avoid distractions, but close enough to organize whole family visits when it was their turn. They played muddy games of soccer or baseball, chasing each other around and asking us for highly coveted stickers. They were so full of energy, so happy and so free. The mothers usually didn’t find these games as amusing as I did; they were exhausted, overwhelmed, and just trying to get the visits done so they could go home. I can’t begin to imagine the strength and resilience it takes for those mothers to care for so many children, and oftentimes other family members, with such limited resources and support.
"The mothers usually didn’t find these games as amusing as I did; they were exhausted, overwhelmed, and just trying to get the visits done so they could go home."
There was a mural painted on the side of a school in one of the communities we visited. The mural was a giant world map, not particularly accurate in terms of scale or geography, but vibrantly colored and decorated. When I saw it, I thought it was quite fitting, as I was working in a team with students and doctors from all over the world, living in a country I had never been to before, speaking a foreign language every day. When I thought about its place in the community, however, I began to wonder what it meant to them. These villages are isolated, by geography and lack of transportation and resources. The children who seemed so free to me would most likely find it difficult to leave their small village, if they ever wanted to. I wondered what they thought of that colorful map on the wall, whether it was an abstract concept of the world beyond their borders, or whether they dreamed of a truly unrestricted future. The child back home in Orange County, of course, might dream of just the opposite – wishing the world were not so vast and intimidating, wishing the world stretched just to the end of the block, where everything in between was familiar and safe.
These are the things I wonder about, the things that keep me thinking about certain patients long after they’ve left. These are the things that connect patients, at least in my mind, despite the vast differences in their lives. Ultimately, the job in medicine is to focus on the patient, or the ultrasound image, but it’s not always easy, or in the patient’s best interest, to tune out the context.
"But mostly, we can’t ignore how strikingly similar we all are at the start – just little flickers of black and white, so simply alive."
We are trained to look at that little flicker of a heartbeat, measure its rhythm and pace, watch as the baby grows and that flicker gets stronger. We are trained to look at every patient, every heartbeat, the same – without bias, without judgment, without assumptions. At the same time, we can’t ignore the world around us, the world that we are working in and the world that our patients live in. We can’t ignore the fact that differences between two patients’ cultures, communities and access to resources may make them seem worlds apart. But mostly, we can’t ignore how strikingly similar we all are at the start – just little flickers of black and white, so simply alive. Maybe if we try to remember that, all the differences we see every day will become just parts of the mural – not terribly accurate, certainly open to interpretation, but mostly just a beautiful mess of color.