Speculum Speculation

Online banking, greater connectivity, and youtube videos aside I'm going to say that the greatest advantage gleaned from the internet is my ability to attend fellows conference in my pajamas. Today, against a background of echoing pagers and familiar voices and while simultaneously trying to teach Emmaline the word rhabdomyolisis (not so much), I was able to learn a few things. All while comfortably wearing my polar bear pants. Outstanding.

Why the lecture on obstetric emergencies for this group of pediatric emergency room physicians? Well, contrary to popular GOP dogma, kids sometimes get pregnant. Good kids. Kids with nice parents who limit their screen time and monitor their facebook and who live in houses with picket fences and dogs named Rover. These kids have sex and they get pregnant and they come to the ER and you code the visit as abdominal pain because you don't want the word pregnancy to show up on their parents' health insurance statement. 

Let me rephrase that. You don't do it to be nice. You do it because a pregnant teen is an emancipated minor and legally entitled to medical confidentiality even from her parents if that is her choice.

So imagine a teenager who has had an abortion. Here, in this country, it would have been performed in a clinic using sterile instruments and she would have gone home that day with a careful follow up plan in place and numbers to call if anything doesn't seem right. But what if she, like the girl discussed in lecture today, was from another country? What if the abortion, which she only reluctantly disclosed after her family had been asked to leave the room, was done in a place where such procedures are illegal? They are dirty, not from an ethical standpoint but from a physical one, and now her abdomen is filling with pus.

In the developing world, 25-50% of maternal death is the result of illegal abortions.

Young girls. Healthy girls. Many of them growing up in cultures where to refuse sex is a patriarchal no no. That is a discussion for another time, but suffice it to say that their deaths are a tragedy. They are victims, not culprits.

So she's in your ER, having just gotten off a plane, and you can tell just by looking that she is in terrible shape. She goes straight to the OR where they try to clean out the pus filling her up inside. From there she goes to the ICU. She never wakes up. They never take out the breathing tube. And two weeks later she dies.

What do you tell the family?

The pregnancy and the unsterile abortion that killed her were her choice to conceal. In death, does that doctor patient confidentiality persist? How much does it add to a family's grief not to know, to feel that the doctors were concealing the truth? On the other hand, how does knowing change the way they remember their daughter, her laughter, her dreams?

I don't expect an easy answer. What I want is for people to realize it is hard, incredibly hard, for the family but also the doctors who care for girls such as these.

In the ER with my own pregnant patient, who is entirely well, who came to see me after scheduling an abortion with her own provider, I realize that the only reason for the visit is that she didn't know where else to go. I'm not magically empathic. She actually said as much out loud. She's a smart girl. Even as she was saying, "I didn't think I could get pregnant the one time we didn't use a condom," she stopped herself to shake her head ruefully and ask, "Does everybody say that?"

Yes. 

So what did she want from me? She wanted to be told it was all going to be okay. We live in a country where abortions are safe. We live in a state where they are actually performed close enough to her home that she can get there and if that is her choice then, yes, she will be okay. She will not die like the patient I heard of today. If she has the baby then, well, she will also probably be okay, though having a baby is one of the most dangerous things women in this country do.

She wanted to be told if it would hurt. Well, not as much as pushing a baby out of your vagina. I didn't say that. Well, not exactly. But what I did say is that I have friends who have had abortions. This thing that no one talks about, maybe we should. Maybe that would help teenagers to make better decisions, both about whether or not to terminate a pregnancy but also about how and when they choose to have sex.

"Are they okay?" she wanted to know, meaning my friends.

"Yes," I told her, with complete honesty. "They became doctors and then they became mothers when they were ready."

The decision will be hers. I can't make it for her. But she didn't need that. She really just needed someone to give her a hug.