Abortion After 20 Weeks

A few days ago, I received an email from one of the many pro-choice organizations I follow. The email was in panic mode:

“URGENT! Your signature needed! Our reproductive rights are being threatened again!”

Two days ago, Congress passed a bill banning elective abortion after 20 weeks gestation. “Elective,” meaning not due to conditions dangerous to the mother (such as preeclampsia or eclampsia), or fetal demise, or fetal malformations that are incompatible with life. Those are still possible. Just not, “I don’t want to have this baby.” I haven’t read the full text of the bill, so I don’t know what other exceptions there are. Stay tuned.

I took a deep breath and wrote a letter, but not the kind they wanted or were expecting.

You see, I have a lot of personal history surrounding both abortion and fetuses, and from where I stand, it’s not so simple. Truth be told, it’s never simple to curtail any life, no matter how tiny or how tenuous.

When I was a 16 year old virgin, in 1970, I was drugged, dragged into a dark basement, and raped so violently that after two reconstructive surgeries my nether parts are still not normal. I ran away, partially because the much older man who did the rapes was then sharing me with his friends and as a young person with Asperger Syndrome I didn’t know what to do, and partially because my mother’s abuse escalated around that time, probably due to my increased vulnerability. I fled from Massachusetts to California, where instead of peace and love I found more rape.

I missed a couple of periods. My breasts were swollen. I had no idea what was going on, since there was no such thing as sex education in the schools at that time, and my parents were phobic about anything having to do with sex. I went to a mobile street clinic and discovered I was pregnant.

Being California, there were choices. I could have the baby and keep it; I could have the baby and give it away; or I could have an abortion. I couldn’t fathom either of the first, so I settled upon the latter.

My pregnancy was past 11 weeks by the time I discovered it. California law required that pregnancies over 12 weeks be terminated in the hospital rather than the clinic because of the different technique necessary and the increased danger of perforation of the uterus. The soonest they could schedule me was in two weeks, at almost 14 weeks of pregnancy.

I’m glad they did it in the hospital, because they knocked me out. All I remember is the OB resident coming to see me afterward in tears, ranting at me about “people thinking they can use abortion as birth control.” I had no idea what he was talking about, or why he was so upset.

Fast forward to 1988.

I was a second year resident in Pediatrics at a big city hospital. My Neonatology rotation included participation on the Perinatal Ethics Committee, which deliberated on matters concerning difficult pregnancies and how to handle them.

There was a woman in her fifth month of pregnancy on the inpatient Obstetrics ward. She was 38 years old and had been pregnant already many times, and had miscarried every time. Her underlying problem was high blood pressure, which prevented proper blood flow to the placenta. She routinely miscarried between 18 and 24 weeks. At that time, and mostly until this day, for specific reasons, 24 weeks was considered the lower limit of fetal viability. Efforts to work around those limits are ongoing, but for the most part not practicable.

But she desperately wanted her baby. The perinatal team knew her well and liked her in spite of her challenges. They felt that if it were technically possible to save her baby, then we had a mandate to do all we could to deliver her a living child.

Now, this lady was no married, upper class, healthy white person. She was black, intellectually disabled, and chronically ill with severe hypertension due to lupus. She was unmarried, lived in a rough part of town, and had a criminal record for theft. In other words, a high-risk prospective parent under any circumstances, and especially for a very premature delivery. What was the prognosis, really, for her to safely and effectively parent a tiny preemie who would, if she survived, need intensive care in the hospital for months and intense home care for years afterward? Not so good. We debated the issue for hours and hours. The lady really desperately wanted her baby, but we were literally not certain we could deliver a viable baby for her, and certainly not a healthy one.

What should we do?

One thing in favor was stress. Normally we think of all kinds of stress as undesirable. We’re always thinking up new ways to combat stress in our lives. But stress is the premature baby’s friend. Stress in utero leads to increased stress hormone production by both mother and fetus, and this speeds the maturation of the fetal lungs. That was one good thing. After the lungs, the greatest challenges are the kidneys, and the skin. In utero, the placenta takes care of fetal waste, but undeveloped kidneys are something we have not learned to adequately deal with on the outside. Likewise, no need for skin inside, but here in the big world, without skin we quickly dehydrate and without its protective barrier, bacteria get in and wreak havoc.

These things don’t finish their development until the middle of the 23rd week. Our job was to keep this lady pregnant until the end of that week, if possible.

The plan was to do thrice-daily ultrasounds of the maternal-fetal circulation. Her problem had historically been that because of her hypertension, her placenta would become calcified, leading to a net reversal of blood flow so that instead of her blood going to the fetus, the blood flow became reversed, so the fetus became starved of oxygen and died. We put her on complete bed rest with high levels of supplemental oxygen, to keep the pregnancy going until that precious 24th week, at least.

In our cutting-edge neonatal ICU we boasted well over 90% survival at 26 weeks, unheard of at that time. That’s because our hospital pioneered the use of pig surfactant, a substance that, when blown into the stiff lungs of a tiny preemie, caused those lungs to become suddenly functional. It was nothing less than miraculous.

(Part of that miracle is that it was discovered by an Orthodox Jewish postdoctoral fellow, who would come into the hospital at all hours to blow a tube of pig lung secretions down a baby’s tube.)

This almost entirely eliminated the biggest barrier to survival of premature babies, the lungs, unmasking the next big challenges, which were and still remain, skin and kidneys. (We don’t have artificial substitutes for either kidneys or skin, but believe me, they’re working on it.) So we knew that if we could get this little girl past that 23rd week, between the stress and the surfactant we’d stand a pretty good chance for having her grow up.

The neonatal team was on call for the moment the blood flow in her placenta reversed. If she made it to 24 weeks, we’d deliver by Cesarian section and then, if she breathed spontaneously or with minimal intervention, we’d go all out. If she did not breathe, we would not intubate her. That was the compromise we worked out.

As it turns out, she never made it to 24 weeks. At 23 1/2, placental blood flow reversed. We had a quick conference and reconvened in the delivery room, where the fetus was removed by Cesarian section and handed off to the attending neonatologist, who happened to be me.

Squirming in the surgical towel they handed me was the tiniest human I have ever seen. I placed her on the scale: 325 grams, about a third of a pound. I’ve had burgers bigger than that! Her eyes were open, and she had all her fingers and toes. She was perfect.

As I laid her very carefully on the cold scale, a hole opened in her tiny face and a huge wail came out! She cried lustily, and I shrugged as I handed her to the NICU nurse.

“She wants to live,” I observed.

“Damn right she does,” said the nurse protectively, placing her in the warm incubator. “Let’s roll!” And they took her to the NICU, where she endured many challenges but never gave up.

I followed her until she was nearly 3 years old, then lost track. She didn’t have it easy. Her mother predictably dropped out of the picture, but her aunt took over and did a great job with her. She never had any of the really disastrous preemie problems (brain bleeds, oxygen toxicity, gut problems, sepsis.) We figured the stress she endured prenatally might have helped. Or maybe, as in the Jewish way of thinking, her soul really, really needed this particular vehicle in order to accomplish its mission.

No matter. After holding that little tiny life in my hand, watching her hang onto that life for all she was worth and actually grow up, there’s no way I’m going to say that a 20+ week fetus does not feel, or is not alive.

The Bed Bug Chronicles

Five years ago, if anyone had asked me what I knew about bed bugs, I would have shrugged my shoulders and stared at them blankly.  Now, unfortunately, that is not the case.  I’ve had much more experience with bed bugs than I can stand.  I know that others have had, and unfortunately are still having, far worse experiences than mine; but you have to understand that mental illness makes it much harder to deal with the anxiety and downright horror an infestation of these nasties can cause.  And there is plenty of reason to believe that if you don’t have a mental illness before you get bed bugs, you may very well acquire one.  There are numerous articles in the psychology and psychiatry journals speculating whether latent mental illness can be triggered by the severe stress and distress that bed bugs cause.

In fact, I just read a case study from the National Institutes of Health documenting the suicide of a woman with mental illness for whom a prolonged bed bug infestation was just the last straw.

Any of you who have had to deal with these disgusting creatures will agree: in the “gross!” department, it doesn’t get much grosser.  They bite you in the middle of the night, when you are asleep and defenseless.  You can’t even feel them biting, because first they inject you with a dose of local anesthetic so you won’t feel their proboscis piercing your skin.  Try to starve them by going on extended vacation; they laugh!  They can live up to a year without feeding.

I asked my rabbi who was responsible for the creation of bed bugs, anyway.  His response?

Hell.”

 

bed-bugs

Oh man, do I agree with him.

My first bed bug experience was four years ago.  I was a patient at an Ayurvedic hospital in South India.  I was extremely ill with a digestive malady that turned out to be a rare form of Cystic Fibrosis.  I had lost 20 lbs because all of the food I ingested came right out the other end (sorry), and I was literally starving.  Regular medicine had decided that I was some kind of crank, so I was getting no care from that quarter.

The Ayurvedic hospital was heaven on earth.  Located high in the mountains of Tamil Nadu, the hospital itself was situated in the middle of a vast tea plantation. Did you know that tea comes from a Camellia bush, Camelia Sinensis?  Well, let me tell you, when hundreds of thousands of Camellia bushes are all in flower, the night smells just like the fragrance the angels smell when they come out to sing in the morning.

But let’s get back to the subject at hand.

One morning I woke up with itchy bumps on my neck.  They looked like this:

My First Bed Bug Bites

My First Bed Bug Bites

 

Note the peculiar proximity to my jugular vein.  My first thought was, Damn, they have accurate mosquitos here.  Then I thought, Hmmm, it said in the brochure that they don’t have mosquitos here.  That’s why you don’t have to worry about malaria like you do everywhere else in India.

The following morning, my neck looked as if someone had taken a pastry wheel (the kind with sharp spokes, for poking holes in pie crusts) and run it up and down my neck a few times–and horrors! my pillow was covered in splats of blood, to match the holes in my neck!!!  OMG.

I ran down to the dining room to see if anybody there could tell me what this was.  A woman from New York gave me a knowing look and pulled some pictures up on the communal computer: yup, no question.  Those were bed bug bites.

I roared into my doctor’s office, panting, and blubbered out my story, spewing tears and snot.  He patted me on the hand and told me it was OK.  It was NOT OK.  I dragged him up the hill to my cottage and showed him the hideous pillow.  He yelled for the servants to come and give me a new mattress.  I barked orders to also clean the bed frame very well, very well.  The staff did not speak English, so I implored Doctor-ji to please, please explain to them.  I think he did, for they grudgingly took their pails full of water and crude eucalyptus oil (I was later to discover why they used eucalyptus oil) and swabbed down the bed frame.

I always travel with my own goose down pillows, because I have two fused vertebrae in my neck, and I have to have the right pillow in order to not be in agony.  So I stuffed my poor pillows into the washing machine (“for the convenience of the guests”) and set it on 90 degrees Celsius, which is just short of boiling.  I won’t bore you with the details of trying to get the pillows dry again, because “for the convenience of the guests” the hospital did not have a dryer, and it was monsoon season, freezing cold and raining most of the time.  Previously, I had thought it entertaining to watch the staff hanging the sheets out on the topiaries to dry, only to snatch them back inside the next moment because it had begun to rain again.  Needless to say, I no longer found that entertaining, now that I was doing it myself.

I fought the bed bug battle for weeks.  Changing the mattress changed nothing.  I moved to a new cottage.  They were there too.  Eventually I learned that  the locally made (and very crude) essential oil of eucalyptus repelled the little bastards, and by soaking the bed and covers every night before retiring, I could get a night’s sleep without worrying about waking up bitten bloody.  Reeking, perhaps, but intact.

Fast forward to August, 2013.  I have just arrived to Jerusalem after a two-month absence.  In June I had rented a tiny apartment, built entirely of Jerusalem limestone quarries, quaint but suitable for my needs. I come and go often, and really just need a place to land when I’m there.

The place came unfurnished except for a large wardrobe, so I brought a large and sturdy camping cot with me from America, to stand in for a bed.  It fit nicely into a golf bag that I used to have for the purpose of flying with odd size objects.

I stayed a few days with a good friend of mine who lives half a block from my new apartment, very convenient, and got everything set up before I moved into my digs.  I’ve stayed with him countless times in the past.  He’s a dear friend whose chief failing is that he is incapable of saying “no.”

And so it was that his good friend, we’ll call him Bob, arrived from a large East Coast city with FOUR enormous duffel bags packed with STUFF.  OK, I get it that he was moving back to Israel permanently, but he was also planning to stay with my friend who can’t say no, and there was simply no room for his stuff and mine.  So I pulled my belongings out from under the pile of his bags, and packed myself off with my few possessions to my little apartment down the street.

Two days later, my friend calls me and says, quite sanguinely, “Guess what?  A big fat bed bug crawled out from under my pillow this morning, full of my blood.  I squashed the sucker.”

I broke out in a cold sweat.  I mean literally, I was suddenly drenched in sweat.  My heart was racing.  I could hear the blood pounding in my ears.  I was having a Bed Bug PTSD flashback!  No, don’t laugh, I mean it!  I couldn’t swallow.  I felt like I was going to faint, or have a seizure, or a heart attack, or die.

“Fuck, Ron,” I managed to squeeze out.  “We didn’t used to have bed bugs at your place.”

“Yeah, I know.  I’m thinking Bob.  He lived in this fleabag room full of roaches and God knows what else.”

“Well, what are you going to do?”

“Uh, what was the name of that exterminator you had over to get rid of the fleas?”   My apartment had been full of fleas when I moved in, so I got Sammy the Exterminator and he took care of it.  I gave Sammy’s details to Ron and closed my phone, still shaking.

Shit, all my stuff had been lying at the bottom of the luggage pile, literally, with Bob’s fleabag flophouse stuff on top of it.  Well, all I could do was wait and hope.

I didn’t have to wait long.  A couple of days later I woke up with bites.  Not only that, but my little dog Noga was furiously scratching.  God, I was hoping it was just the fleas again.

But it wasn’t the fleas.  The next day I found a big old bed bug dead between the camping mattress and the cot.  I picked it up in a tissue and put it in the freezer for evidence.

I didn’t call Sammy.  I didn’t like how he had handled the extermination job at Ron’s.  I’m not going to go into the technicalities of bed bug extermination, but it’s a big, long, involved, labor intensive process, and Sammy hadn’t done any of that.  So I called a big extermination company that’s supposed to be the only outfit in Israel that really knows their bed bug business.

The guy showed up in a company uniform, very official.  He took one look at my stone cave of an apartment, and said, “You can’t have bed bugs here.”

“Why not?” I said.

“Because you can’t.  I’m a professional, and I say you can’t have bed bugs here.”

I showed him my bites.  I went to the freezer and got my frozen bed bug specimen out, but when I opened the tissue it fell apart.

“That is not a bed bug,” he stated triumphantly.

“Look at all the cracks between the stones!  Look at that old wardrobe!  Look, I found that bed bug (he snorted a snort of contempt) in my bed!”

He tore the covers off my cot and announced, once again, that I could not possibly have bed bugs there because he was a bed bug expert.  Then he took his little flash light and looked into the sleeve where the tube of the cot goes through the fabric.

“You have bed bugs,” he announced officiously.

“Where?  Where?  Show me!”

He pointed his flash light into the sleeve.  I peered.  There was a whole colony of bugs in there, big ones, little ones, cast-off molted skins….I felt both triumphant and sickened at once.

We had a quick huddle about what to do, and concluded that he would take the cot away and “recycle it,” whatever that means, because if we put it in the dumpster it’s certain that someone would take it home with them, even if we marked it “bed bugs,” because that’s how it is there.  So he folded the thing up, in spite of my fears that he would dump bugs and eggs and everything into the cracks between the stones of my floor, and took it outside, announcing that it would be 200 shekels for the house call.  I shelled out 200 shek.  He stuffed it in his pocket and stumped away with my former bed.

To be continued…..

 

Rant on the Insidious Appearance of the Penultimate Comma

Yes, I know this is a blog on mental health, not on grammar.  However, a phenomenon has crept into the written English language that threatens my mental health, since it causes me to scream every time I encounter it.  It is the Penultimate Comma, which is a comma that appears between two modifiers preceding a noun.  It looks like this, when used properly:

“A big, black dog.”  (You could also correctly write “A big black dog.”)

When used improperly, it looks like this:

“A white, Cadillac convertible.”

What’s the difference?  It’s very simple.  If you can hypothetically insert the word “and” between the two modifiers, you can substitute a comma for the “and.”

As in: “A big and black dog.”  You wouldn’t necessarily say it that way, because it sounds awkward, but it’s grammatically correct to do so.

However, to say: “A white and Cadillac convertible” sounds bizarre, if not ridiculous.  

I know from whence this grammatical misconception arose: school children of this, and sometimes the previous, generation have been taught that if you can say “A white convertible” and also “a Cadillac convertible,” then you should go ahead and insert a comma between “white” and “Cadillac.”  This is wrong.

Why?  Because, dear readers, it sounds utterly absurd.  That is why.  If you read it out loud, placing the pause of the comma where it is written, you will see.

Another incorrect example:  “An expensive, Tudor house.”  No, no, no!  Yes, it is an expensive house, and it is also a Tudor house,  but it is “an expensive Tudor house” and that’s that.

Another correct example:  “An expensive, garish negligee.”   Why?  Because you can say “An expensive and garish negligee.”  Very simple.

How do I come by the audacity to write this vituperous essay on the Penultimate (next-to-last) Comma?  It is simply a product of thirty years, more or less, of editing various  book manuscripts and hundreds of medical and scientific papers, as well as a couple of dissertations.  I learned by Experience.  Period.