Assume the Position: Memoirs of an Obstetrician Gynecologist (15 page)

     One Sunday morning when I was watering my grass outside my house, I got a call from one of my partners who asked me to come in to do a hysterectomy on his wife.  I knew her well, personally and socially, but she was not and had never been my patient.   His mother was my patient, but not his wife.  He told me she had come into the emergency room during the night with heavy bleeding and he decided she needed, and she decided she wanted, a vaginal hysterectomy, removal of the uterus through the vagina without an abdominal incision.  I told him I was uncomfortable with this since she had never been my patient. I didn’t know her from a medical standpoint but they were both insistent.  I trusted his judgment.  I knew they wouldn’t have asked if they both didn’t want it done and if he felt it was needed.  Besides, her labs indicated she was indeed bleeding heavily.  They had three children and were done with childbearing. So in I went, examined her, and decided to proceed.  They would have had it no other way.  The surgery went without incident. That one time she became my patient. The following day in the hospital on rounds I decided to do a medical workup to see if there had been any other underlying medical problems that could have caused the bleeding.  Sure enough she was diagnosed with a rather severe thyroid disease that needed to be treated medically, undoubtedly the real reason for the abnormal bleeding.  Had it been diagnosed before the surgery the procedure could likely have been avoided.  I would always screen for thyroid disease in my patients having abnormal bleeding, and rarely if ever was it diagnosed. It figures that in this case that would happen.  A lesson learned.  I had a happy patient, a happy husband and partner, but an unhappy surgeon!  My Chief of Service at Pennsylvania Hospital would have been unhappy with me, too, if I presented this case at morning rounds.  One should never deviate from what one knows to be good medicine.

     Skilled medical and surgical provision of abortion services is necessary, appropriate, legal, and a diminishing skill which needs to be preserved so that women’s health care will continue to be top notch without stepping backwards into the dark ages from which it emerged almost 40 years ago.  I can’t honestly say that when I was considering medicine I gave any thought to whether or not I would be involved with abortion services, nor did I seek it out or proselytize for it.  It just became part of my life and training when I chose the field of Obstetrics and Gynecology.

     When in college I enrolled in an introductory philosophy course, about which I knew nothing, to broaden my horizons. Fortunately it was offered as a Pass/Fail course rather than for a grade.  We had to write papers about all kinds of subjects. I just couldn’t get my head around how to write a philosophy paper, unlike papers I had to write for other courses in college.  One of the assignments was about the topic of ‘Abortion’, which I delved into deeply. It was really my first exposure to the topic and the first time I had given it any thought. In 1968 it was pre Roe versus Wade and hotly discussed. Abortion was still illegal, yet women were finding ways to have them performed without regard to their own health.  I couldn’t possibly take any other position than pro choice supporting abortion.  There was just no other way for me to see the issue. I wrote a strong pro-choice abortion paper.  For me a woman’s rights to control her own body superseded anything else no matter what the circumstances of the pregnancy. It was her body and she could do with it whatever God given right she chose to do with it, as could I with mine. It was as simple as that. There seemed to me nothing more desirable, sweet, and pleasant than a wanted pregnancy, and from the viewpoint of a sociology and psychology student, nothing worse than an unwanted/unplanned pregnancy for the fetus, the mother, the family, or society at large.  It seemed black and white to me.  I got my first and only red “F” on a paper I had written in college.  Not so much for the stand I had taken and supported, but for the fact that I took a stand at all and refused to see the merits, pros and cons, of the other side.  Fortunately, I passed the course but this solitary event played a large part in shaping my early views about women, society, reproductive and individual rights and choice.

     During one evening shift in the emergency room as a second year medical student in Center City Philadelphia, a young 13-year old African American girl was brought in with an acute abdomen, hemorrhaging from the vagina with fetal tissue visible at the cervix, the opening to the uterus. It was 1973, and Roe versus Wade had just been passed by the Supreme Court with a 7-2 decision giving a woman the right to privacy under the due process clause of the 14th Amendment of the constitution.  This extended the right to a woman to have an abortion until the age of fetal viability.  It overturned and voided a Texas state law of criminal abortion.

     For this young girl in front of me the law was too little and too late.  It was never clear what the circumstances were that led her to a back alley in North Philadelphia, where some uncaring and untrained profiteer put a coat hanger inside her cervix and uterus to cause the abortion.   She was left septic, hemorrhaging, with a perforated uterus and ruptured intestines.  Septic shock is never a good thing to have or to watch.  Her medical team, of which I was just a non-participant observer at the time, struggled for days to keep her alive.  It was an eye opener for me - an emergency hysterectomy, removal of tubes and ovaries, bowel repair, IV antibiotics, days in the ICU before her senseless death at the age of 13 from septic shock.  Almost everything I had studied and learned as a sociology major in four years of college was embodied in this one destitute young woman in front of me for days; poverty, illiteracy, family dysfunction, lack of contraception and access to good health care, sexual abuse, social ills, profiteering, and abortion.  All of society’s terrible problems were brought to bear on this one young woman.  It was a horrible thing to see and watch, and left an indelible impression on me that I carry with me to this day.  It was at that moment that my thoughts about caring for women began to crystallize. Hopefully as the years went by, Roe V Wade would bring this all to an end.  In my mind the Supreme Court got it right then. No Court since then has seen fit to overturn this momentous decision and hopefully none ever will. “Settled law” is the term used now, and settled it should be no matter who sits on the Supreme Court now or in the future.  To overturn this law will send our country and our women back into the Dark Ages.

     During my second year of training at Pennsylvania Hospital I spent three months in what was called a Family Planning Rotation, where we discussed contraceptive options with patients, performed permanent sterilization in the form of tubal ligations on those women who no longer desired fertility, and performed pregnancy terminations on women who requested the procedure.  During the day we attended the Family Planning clinic, prescribed birth control, placed IUD’s, fit diaphragms, discussed permanent sterilizations and scheduled and performed tubal ligations.

     We also learned the ins and outs of surgical abortion training, an integral part of our training program.  Since Roe V Wade was now the law of the land, abortion training was critically important to learn how to size an early pregnant uterus, what various kinds of procedures we needed to learn and perform depending on gestational age, and how to manage and deal with potential complications.   Anyone could have opted out of this training if they had objections but in our program no one did while I was there.   Early abortions up to 12 weeks, the first trimester, were handled in the outpatient surgical suite under a brief general anesthetic and a procedure called a suction D and C.   Second trimester abortions were done by intra amniotic prostaglandin induction of labor that required learning how to perform amniocenteses, placement of a needle and catheter into the pregnant uterus through the abdomen, instilling a medication into the uterus to cause labor and subsequent delivery of a stillborn premature fetus.  For me it was all part and parcel of caring for women.  There was no judgment as to circumstances that brought these patients to us.  But at their request, and within the guidelines of the law, we learned the skill of providing a safe, simple service that preserved their fertility for later years when the women were ready to have children.  All the women followed up with us in the Family Planning clinic.  It was as it should be to guarantee women good health and reproductive care and rights.  There were no advertising of services, no protests, and no mishaps and loss of fertility and life as I had experienced a few years earlier in the Hahnemann emergency department.

     First trimester pregnancy terminations were already a routine part of our practice in Phoenix when I arrived.  One of my partners had been medical director of Planned Parenthood during his first year in Arizona.  He established a referral network for pregnancy terminations in the city.  Our group was one of a number of providers for early pregnancy terminations.  In those days Planned Parenthood did the counseling, the testing, and made the referrals.  Over subsequent years they eventually hired physicians in house to do the procedures and stopped referrals to the community physicians, a business decision with which I disagreed. It seemed to me that money became more of a motivating factor for the organization rather than counseling which had been their charter. But so be it. That was their decision.

     My partners chose long before I arrived to do only first trimester pregnancy terminations that were performed in the office under a local anesthetic and sedation early in the morning before regular office hours. This was a progressive move for me since in training all the procedures I had performed were accomplished under a general anesthetic in outpatient surgery.  So I quickly had to develop in office skills at sedation and local anesthesia, and operating on and talking to patients who were awake.  It was a valuable skill to have learned quickly in private practice that came to serve me well for the future, as well as lessen risk for the patient.  There was no advertising for these procedures.  There were no protests outside the office.  Patient privacy, protection, and comfort were important to us.  We gave each patient the time, counseling and comfort needed to make sure of her decision without the stress of people carrying placards and harassment. We followed up with the patient three weeks later with a routine exam, a pregnancy test to make sure it was negative, and contraceptive counseling.  Many of these forever-grateful women became life long patients of the practice and we became their obstetricians over the years.

     Not long after my arrival in Arizona, Senator Barry Goldwater and his wife sponsored a party at his home in Paradise Valley, Arizona to benefit Planned Parenthood.  A six term US Senator and former Republican Presidential candidate against Lyndon Johnson in 1964, he was the true father of Republican conservatism and a Libertarian.  He always frankly spoke his mind.  Although I rarely agreed with what he said politically I admired him for his honesty and patriotism, in short supply nowadays. So I chose to go to his home.  As most folks did not know and as today’s conservative and Tea Party Republican’s would vilify him for, he and his wife Peggy were strong supporters of Planned Parenthood, a woman’s Right to Choose, and keeping “the damn government out of people’s bedrooms” as the Senator so aptly put it.  This was consistent with his Libertarian and personal philosophy.  One reason he lost the Presidential election was because he did speak his mind and not everyone liked what they heard, but he was true to his beliefs and honest which I greatly respected.  Today’s Republicans would do well to read their history books.

     So three months into Arizona I found myself inside Senator Goldwater’s beautiful home on a mountaintop overlooking the city.  His wife spoke and they were gracious hosts.  We had free roam of his house so my wife and I poked around.  We were strolling, cocktail in hand down a long hallway when the Senator appeared from inside a room.  He introduced himself and asked us if we would like to see something special.  He took us into his Gun Room lined with cabinets filled with rifles and guns of all sorts.  He pulled out a ladder, climbed it (he wasn’t a young man then), opened a cabinet, took down a rifle from the top cabinet and put it in my hands.  I was polite, non-gun supporter that I was.  After all I was in his home.  There wasn’t much I could do but take it.  He asked me if I knew what I was holding.  Other than ‘ a rifle’ there wasn’t much else I could say.  He proceeded to explain to us that it was the best rifle ever made, one used by the ‘Red Chinese” as he called them, in the early 1900’s.  And so my introduction to Arizona continued.

     One of the hospital committees on which I sat was Credentials. This committee reviewed and gave hospital privileges to new staff applicants.  One monthly meeting there was an application from an OB GYN doctor, well trained, an Army veteran, applying for staff privileges.  His credentials were in order and there was no reason to deny him admitting privileges.  The only concern for me was his letterhead on normal size stationary with his name in such large bold face print that it consumed about 2/3 of the page.  I had never quite seen professional stationary like that before and it raised a red flag for me.  As it turned out he performed late second and even early third trimester abortions. He was one of the only physicians in the State of Arizona who did so.  He pushed the limits at all ends and wasn’t one of my favorite people on earth.  He was all over the news in the subsequent months.  There were always protesters in front of his office.  He loved the attention.  One day I saw him in the operating theater changing room, bullet vest on and holstered pistol under his arm.  This was his chosen life.  Years later as I followed his career, he was accused and convicted of sexual molestation of a patient and wound up in State prison.   For some reason I wasn’t all that surprised. Fortunately, he was a unique person.

     As to the women who sought abortion, there was truly nothing they had in common other than they had an unwanted, unplanned pregnancy.  They came from all walks of life; the rich and the poor; the black and the white; the professional and the non- professional; the religious and the agnostic; the pro choice, and the Right to Lifers.  Yes, it was interesting to see some folks come off the picket line for the service we provided when it affected them.  Whatever stereotypes there are out there about women who seek abortion should be forgotten.  Pregnancy is a momentous decision in anyone’s life, whether an unwanted or wanted pregnancy.  It should not be forced on anyone for any reason whatsoever, for there are truly few things in life that are so life altering. Thus to legislate against a woman’s right to choose is society forcing a woman to do something that she may not want nor be able to afford financially or emotionally, and worse may be ill prepared to handle.  Bringing a child into this world to either a set of parents, or a single parent, through coercion is no way to begin a life. It will not bode well for the unborn individual.   I give the utmost respect to those women who are able to have enough foresight and courage to make this difficult decision.  No one but them, in consultation with their health care provider, their families, and their significant others should be interfering with an individual’s right to make this decision.  Senator Goldwater was able to see that, and so should everyone else from the conservative side of politics that think they know what is best for a woman and seek to legislate their beliefs into a part of life where legislation does not belong.  The Supreme Court got it right when it said we are all entitled to the right of privacy under the constitution.   For any future providers of women’s services, it should be known that this is a skill, like any other medical skill, that should continue to be taught, learned, and provided with privacy and dignity for everyone concerned.