Interpreterofmaladiescover“Her placenta had weakened and she’d had a cesarean, though not quickly enough. The doctor explained that these things happen. He smiled in the kindest way it was possible to smile at people known only professionally. Shoba would be back on her feet in a few weeks. There was nothing to indicate that she would not be able to have children in the future.”

Introduction

Pregnancy related emergencies are easy, right? Simply divide into categories based on trimester, then subdivide into pain categories or presence/absence of vaginal bleeding. Then decide which need ultrasound, transabdominal versus transvaginal. Finally which cases are viable and which are not. Follow up the case with discussion of the disposition, and you are off to the next patient.

But wait, is this really all there is to pregnancy related emergencies? 

In the short story “A Temporary Matter” from the book Interpreter of Maladies by Jhumpa Lahiri, we see two people have their hopes and dreams for their future child crushed during one of these many pregnancy related emergencies that we have learned so well. We see how the doctor floats into their lives like a feather, and leaves no impact as he floats away from them. Medical treatment is given, without concern for the emotional consideration for those patients.

Relevance

Consider how much emphasis (rightfully so) is placed upon palliative care and end of life discussions. Interestingly, rarely does death of the fetus enter into consideration for those topics. Pregnancy related emergencies are still deaths, maybe not in the same physical sense as end of life discussions. However, these are deaths of potential, of the future, and death of lives that will never be lived, clothes that will never be worn, and cribs that will forever be unused. We provide our patients a great disservice when do not stop and address the emotional and social aspect of pregnancy emergencies.

We also provide our learners a great disservice when we do not include pregnancy emergencies in the same conversations that we have around palliative care and end of life discussions. And our patients suffer greatly for it with doubts swirling around the fact that the loss of the fetus was somehow their fault, that something is wrong with their body, or perhaps they are unfit to be parents.

Ultimately, having a better understanding of how to deal with the delivery of the news especially of first trimester complications is a skill that EM physicians in particular have to develop. These patients come to us in the emergency department, not to their OB doctors. While the OB doctors can develop a strong relationship with patients over the 9 month period, EM physicians don’t have that benefit. These emergencies fall within our specialty and we must do better for our patients through acknowledgment of the life altering impact the death of a fetus can have on one’s life.

Brief Synopsis

Jhumpa Lahiri spins a beautiful tale in the short story “A Temporary Matter”. This story is found within the Pulitzer Prize winning book titled Interpreter of Maladies. We meet Shoba and Shukumar a few months after the stillbirth delivery of what would have been their first child. Rather than mourn and come together in the months that have passed after the traumatic event, the couple have drifted apart and now are at the tipping point of falling apart. And though the doctor is a mere footnote in their lives, as read in the above quote, clearly this event has broken something in the core of each of their beings, and ultimately the readers see that the death of their future child ultimately breaks their relationship beyond repair. The well-constructed plot of a scheduled power outage for one hour over the course of the week forces the characters to confront each other without the distraction of TV or other electronics. As the characters sit in the darkness nightly at their dinner table, faces only lit up with candles, they open the barriers of their emotions and for the first time finally acknowledge the deep hurt that was caused from their loss.

Take Home Points

  • An eloquent short story that creates a hauntingly beautiful account of how pregnancy complications and death can lead to the slow unraveling of a couple and the life that they once shared.
  • Encourages reflective thought in the readers to try to understand what happens to our patients after the delivery of bad news.
  • Expands what ED physicians typically consider under the topic of Death and Dying in order to deliver more comprehensive healthcare to our patients.

Book Club Question Corner

  1. What are the best modalities to educate learners on improving competency in difficult conversations?
  2. How can ED physicians improve the identification of patients who are at high risk for depression and suicide after receiving bad news?
  3. How can ED management of first trimester vaginal bleeding be improved in the ED?

Post your responses to our questions or comments below or tweet us using the Twitter hashtag #ALiEMbook.

We will post a curated commentary of the October #ALiEMBook club Twitter and Blog discussions 1 week after the release of this review.

Book: Interpreter of Maladies [Amazon discussing only the short story “A Temporary Matter”   
Author: Jhumpa LahiriISBN: 978-0395927205
Book Club Review written by: Nikita Joshi, MD
Peer Reviewed by: Teresa Chan, BEd, MD; Michelle Lin, MD

Disclaimer #1: Neither I nor this website have any affiliations, financial or otherwise, with the book or Amazon.com.

Disclaimer #2: By participating in this online discussion, we reserve the right to publish your attributed thoughts in a synopsis for future print publications.

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD

@njoshi8

Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions
Nikita Joshi, MD

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