16 August 2011

The Procedure

(This was written several weeks ago – refers to all month of July)

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. (But are the babies different? Yes...) 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.
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.


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