10 December 2015

Regarding the right to choice and Planned Parenthood...The Procedure.

This represents a minority of what PP offers. Further writing on prevention to follow.

As a medical student or as a doctor, I have worked in California (San Francisco and Fresno), New York, Cameroon, and Kenya. In the US, I’ve worked in abortion clinics (sic: family planning clinics) in San Francisco and in New York. I’ve never had much to be afraid of.

The below was written in July of 2011, as a medical student in an abortion clinic in San Francisco. Reposted.

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Today I used sound waves and a plastic transducer to take moving photos of a fetus-squiggle. I was outside, it was inside, and now it doesn’t take long for me to find the uterus, to see the black-filled-collapsible bladder on top of the double-stripe collapsible uterus that now, in pregnancy, isn’t so collapsible (potential space). The black-fill is water, and there’s a tiny yolk sac (depending) and there’s a little squiggle (this early). And it turns and turns and turns on a stalk, and I have to move, patient, to capture it. Length-wise. Freeze. I measure. My machine converts that to weeks.

And I print the photo, attach it to the woman’s chart on which I’ve written LMP/Gs and Ps/prior c-section or surgery. Bleeding or pain? Prior ultrasound?
I’ve filled in provider (the attending), the clinic, the date, and the patient’s name, DOB, medical record number are stamped at the top of the carbon-copy page. White copy on top.
I write in the length I found (if it’s first trimester-early, it’s crown-rump length - descriptive, no?) and I write it in mm and I write the gestational age.
I mark: + IUP.  + FCM
Single, intra-uterine pregnancy
Fetal cardiac motion

Under “reason for exam” I write “dating – undesired pregnancy.”









Every day for the past month I have been working in an abortion clinic.
And three days a week for the past 4 weeks I have done abortions – yes, I, at least once on each of those days. And at times more (depending on patients – can the student doctor do it? Yes/no. Would I let me, if I were the patient? Yes/no).
On the other two days, I’ve been helping to prepare for other abortions.

These are TABs or VIPs – Termination-abortion (as opposed to SAB, Spontaneous-abortion, commonly known as miscarriage).
VIP. Voluntary Interruption of Pregnancy.

This is not a treatise on abortion. This is not political. This, simply, is.

***


I’ve been working in an abortion clinic – it’s part of my education. It’s my fourth year, now, so I chose this. I chose to work here. A clinic in a large-liberal city in the United States. Where we are, at this clinic, we don’t have to deal with protesters or laws forcing doctors to do things doctors shouldn’t have to do or say. Legalities interfering in even the conversation of the doctor-patient relationship.

There are legalities in every part of medicine. We learn medico-legal speak. We learn what to write, what not to write. How to cover yourself and everyone else.

And for billing purposes, I write “undesired pregnancy.” That is the reason for the ultrasound.

And I do ultrasounds.

***

It doesn’t matter what the stories are; I don’t need to tell them.
My patients have been mothers of 3, high school students, animal trainers, women with master’s degrees (spoke 5 languages) now "without a home; if I have one more child my family is going to ...." Another, talking on the phone to get furniture delivered and 4 kids picked up from school… taking a day off from school + 2 jobs.

Twenty, three kids, here on a bus alone (can’t tell anyone at home), wandering around all night..and that’s why she showed up so early, and why I didn’t want to let her into the clinic, yet, when I was the only one there (protocols? Liability? Who knows. Or my laziness and wanting to finish breakfast, studying, and work for the day before anyone came in whom I had to talk to).

then the other one whose entire family lives on the same street
or the one with a two year old and a six month old – she’s 18.
or the one whose mother is there to hold her hand
or the one whose partner is pacing, anxious, in the outside waiting room
or the one whose social work/case manager is the one in the clinic, in the ultrasound, in the procedure, holding her hand
it was a different one who came from the psychiatry floor
it was a different one and a different one and another one who didn’t know she was pregnant
it was another one who had had to cancel three appointments – mother-in-law sick, died, funeral, then she was sick, then something else happened… but today, she had a day off, and she could do it.
(same for another, who luckily didn’t have to miss one of her summer school class days).

This is what keeps my day and my job alive, vibrant, constant, and me invested in what I’m doing with fresh (tired, tired, tired, red) eyes and hands, again.

Otherwise, it doesn’t matter.

Some are there for fetal anomalies (abnormalities? wide, wide range), chromosomal abnormalities (from amniocentesis; some, we know exactly what they mean – Down’s syndrome, etc. Others, it’s not clear, exactly, just clear it would be bad. Bad). Fetal demise (died inside. Didn’t come out. Could be an incomplete miscarriage, could be…whatever. Something happened. And something inside is dead and has to come out). And then there is every other imaginable reason.

But it doesn’t matter, does it.

***

As a future physician who will specialize in HIV/infectious disease, I shouldn't feel differently about my patients with AIDS-by-blood-transfusion or AIDS-by-heroin-shooting-up.  Health care worker? (yes, I identify more here). Unprotected sex, bad luck, the traditional birth attendant in Cameroon, the wife of the husband who was with the teenager and all those other ones...man in the same situation. Teenager (young). Before HIV was known about and how to protect from it. After. 
The medical treatment is the same. The clinical treatment, patient in the clinic, my patient in front of me, should be the same in that moment. I'd like to hope that one-to-one, ceteris paribus, it will all be the same.

But it doesn't matter, does it. The how or the who.

If I feel differently about the ones with anomalies or chromosomal abnormalities
If I feel differently about the fetuses that were absolutely desired pregnancies but, for some reason, the pregnancy can’t be continued – health, health, dying, fetus dead, health .

But no one’s happy to be here.
No.
The staff are happy to be in this amazing clinic, to be working together, doing this work, helping – counseling for psychosocial, support where there might not be any other in this woman’s life. Doing something small. Having a positive impact. And in this clinic, at least, family planning and contraceptive options are a big, big part of the counseling. Looking toward the future. No one actually wants to do this again - the providers don't want to see the same patients again. The patients don't want to be here again.

No one is happy to be having or doing an abortion. That's not the word.

Nothing is easy about this. In the beginning, it felt different – believing in, supporting abortion rights – and being the one who performs it. Is it? If I weren't in medicine and had the same socioeconomicpoliticalhealthcare views, I wouldn't be on the side with the hands-in-gloves, the mask on, concentrating on the procedure. 
But I am in medicine, I want to be in medicine, and that's part of the views, anyway. Getting to enact - getting to be part of extending health care, of making that a more positive experience for people who might not have those in a power structure. Respect. Just...being there. Like Peace Corps. Being there with whatever skills you have, working to learn as much as possible, always learning, and working because you care so much about it and about what you're doing. Lucky to get to do that. Lucky to be there, on this side. And that's all.

***

Before I started medical school, there was one procedure I was looking forward to learning:

This one.

I didn’t want to be a surgeon; I wasn’t looking forward to learning about appendectomies or heart transplants or venous grafts. I had no conception, yet, of so many of the things I would come to love in medicine. I didn’t know.

This, though – I knew. It had nothing to do with the procedure itself. This is, again, the privilege of medicine to me – and the responsibility, or what I feel it as. I’ve worked in places where abortion is illegal (though I haven’t worked in any of those places in the US, where everything is an unbelievable barrier). I’ve seen the sequelae, actually, a few times. And I’ve read about it (who hasn’t?), even back to my John Irving days and The Cider House Rules (book. better than movie). I wanted to be able to provide safe abortions. Safe. I wanted to learn how to do that, not just a safe procedure but a safe space to come for it. I want to fill in the gaps, in medicine. The things where there aren’t enough people (just need to be filled) or any at all.

Here’s a gap, to me. It’s a place I can fit.

Nothing is easy about this, and I don’t think it ever will be.

Nothing is easy about this. I'm learning. I'm going to keep learning. The skills will build. It won't be easy.




~j

14 November 2015

# Porte Ouverte

le 14 novembre 2015



It was ten months ago that I wrote about freedom of speech, of words, of the privilege of pens, and of those were killed, in some ways, for that. #Je Suis Charlie. Today, yesterday, it’s freedom of assembly. A concert (could “death metal” become more ironic?). A soccer game. Restaurants. Freedom of movement, of passage. The borders are close to closed. Famously, in the 1830s (as also depicted in Les Misérables), Paris was barricaded, fighting from the inside. Seventy years ago, there was the Maginot line, there was “Free France” and my grandparents fighting in the Resistance, there was my old favorite movie, La Grande Vadrouille, with the propeller plane landing just over an invisible frontier and then escaping back to England.

I still don’t know how much we should take for granted. There is a UN declaration. But not even every country is counted in that.

I commented to a friend that this—ISIS, all of it—is like a terrible, blockbuster movie for July 4 weekend. Except I don’t know who the hero is. There isn’t one. In another friend’s village in Cameroon, he discovered that people believed that in action movies, those who die, die. Ebola was that. I have trouble truly conceiving of so much destruction I have not experienced except in fiction. I know personal tragic and tragedies. I’ve seen babies, so many babies (and so many adults) die of AIDS. And TB. And malaria. And diarrhea. And malnutrition. And tetanus (the most banal-sounding shot I give my patients to check off the 10-year mark) : a five-day old with lockjaw who died because he couldn’t feed. And there was nothing else to do. I’ve seen that. I’ve been in shantytowns. I was in Kenya six months after buildings and people were burned in the 2007 elections. I saw the burn marks. But I’ve never been in it.

11 January 2015

All the dangerous things we do with our hands

le 10 janvier 2015


Wielding pens. Waving swords. Stopping traffic.
                                                                                                                                  
I’ve believed that for a long time, not just in the old adage that “the pen is mightier than the sword.” As a writer and a doctor, one of my greatest hopes and exultations in earning my MD was the power and respect the degree bestows, for better or for worse, deserved or not, to be a spoken/outspoken advocate, and to be published for it.
I use writer in the sense of “someone for whom the act of writing is not an option; someone for whom writing is as necessary to existence as is oxygen.” I use doctor in the sense of not just the traditional physician and caretaker for a body and a person, but in the Latin derivation of “doceo, docere – to teach.”

Almost every sentence and every paragraph here starts with I. There is, too, now, “Je suis Charlie/ I am Charlie,” for what it’s worth, for belief in and disbelief against the recent attacks in Paris of freedom of speech.

I have recently felt ill, paralyzed, galvanized by moment and by turn by the deaths of Ebola, inequalities in Africa and health systems in Africa, prejudice, hatred, and fear of those of African descent living in the United States, focus on a few individuals sick in a country where they can be taken care of versus thousands upon thousands in countries whose fragile infrastructures are being destroyed; by injustices perpetrated by institutional racism across the country and most poignantly, most close to home in New York, a system in which I, physicians in general, anyone in a hierarchical position of power is complicit, where I weakly, as a primary care physician, offer flu shots and preventative measures to my patients who, in the South Bronx, are more likely to go to prison than to college, who could be stopped and frisked on the basis of nothing, who fear and are injustly feared on a daily basis.