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.

Life is Tenuous At Best

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Atina the Amazing Malinois was trying to climb this tall tree that you see here.  I looked where her gaze was riveted, and thus is what I saw: the back end of a raptor of some sort, white underside, soft, with enormous grasping talons.  I knew the rest of it must be on the other side of the branch the corpse had been draped over, or rather, dropped over by the triumphant winner of what must have been a hell of an aeronautic battle.  No blood, which points to a slam from above, a tactic used by other raptors to rid themselves of competition in their hunting territories.  Here is the other side:

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The young raptor’s beak curves off to the left.  You can see how she is just draped across the crotch of this piñon pine, as if she was simply dropped there.

Well, she was.  I’ve never seen anything like this before.  She was too high up to have been put there by people, who use this place in the forest on the Coconino Plateau, close to the Grand Canyon, as a hunting camp.  You can tell from the numerous white-picked skeletons of young elk and deer, headless and mostly whole except for the parts easily hauled off to be picked by the eaters of carrion.  And the young raptor, so far, has been left alone by Nature’s cleanup crew, so it must have happened very recently.

I had a heart attack five days ago.

It happened at about 6:15 on Monday morning.  I was awakened by a piercing pain on the right side of my head.  My blood pressure has been out of control lately, and I’ve been trying different meds to bring it down.  The one I’m on helps some.  I tried a tiny dose of a beta blocker, but my pulse went down to 48 and stayed there.  The next one clashed with my lithium so I couldn’t take that.  Another one is now waiting for me at the Walgreens in Flagstaff, but I’m chilling on the Plateau.  I’ll pick it up tomorrow.

Monday morning.  When I had the big pain in my head I thought, well, here it is, now I’ll really lose my whole left side.  At least language will be preserved, though, since the stroke is in my right brain.

But that pain went away, and suddenly my left chest got crushed by a great weight.  The weight also crushed my throat.  I couldn’t believe it.  I could barely breath.  My chest wouldn’t move.  I couldn’t move.  All I could do was wrap my arms around my chest and moan.  Atina plastered her full length against my side, panting.  I also panted.  I couldn’t expand my chest without aggravating the already excruciating heart pain.

It took maybe two hours before I was able to move.  And the rest of that day, all I could manage was to make my way from the bed to the bathroom, and back to bed.  Atina did get to go outside, but not for our usual two to three mile walk.  I gradually recovered my energy over the next few days.  I think I’ve been having some episodes of angina, heart muscle pain that comes and goes.  I’ve been having that for some time.

Listen, I found out the body does not like heart pain.  At all.  When the heart is not getting sufficient oxygen, it screams.

This is the third episode of heart pain I’ve had.  The first was maybe two years ago.  That time the pain woke me from a deep sleep.  It sat on me for hours.  I kept thinking, I should perhaps dial 911, but the phone is on my bedside table and I can’t move.  They always tell you it feels like an elephant is sitting on your chest.  They are right.

I had a third, smaller one in between the bigger ones.  That was when I tried to seek care at a large hospital with a large reputation, and ended up leaving without being seen because they were so rude to me I thought I was going to have a stroke.

I’m not afraid of dying.  I am afraid of the medical establishment, and I am afraid of having my life even more dominated by tests, invasive procedures, and “experts” than it is already.

For example, the only real way to find out what’s going on with my heart is to do a cardiac catheterization.  They thread a fiber optic tube through a blood vessel in your groin, all the way up into your heart, and from there they shoot some dye right into the three major arteries of the heart, and watch where it goes on a screen.  This way they can see whether the vessels are blocked, and if so, where and how much.  If the vessel is only partially blocked, they can open it with a balloon and maybe put a stent in there to keep the vessel open.

That sounds pretty simple, and most of the time it is.  But my blood vessels are very friable, meaning that they rupture easily.  Like, just opening a cabinet door, or walking over the edge of a rug.  Any little bump or stress, and I’ve got a painful hematoma.  So a major vascular procedure would be terribly risky. 

I’m much more afraid of a cardiac cath than I am of a crippling or fatal heart attack.  I just have to figure out how to save Atina from being locked in the van with me if it happens.  I’d call someone, but when this happens I’m unable to move.  So I’ve taken to leaving the doors unlocked at night.  Hopefully someone would show up eventually and let her out.

I wish all this grim stuff was not reality.  I have so many things I want to do, finally, and now this.  I feel as if I’m in the grip of some evil force that is making my life into a big joke.  I’ve been feeling that for decades, but the joke is getting worse and worse.

Maze

It’s like being in a maze, where you turn a corner and run right into a brick wall. So you know that that’s not the way, and you turn about and go a different way.

Due to the height of the walls of the maze, it’s impossible to get any perspective on anything. You only know where you are at this point in time and space.

This is not the kind of maze you spend all of your time trying to find your way out of. On the contrary, we are trying to find our way in.

Back From The Dead, For Now Anyway

Atina lay on her bed painfully struggling to breathe for hours that felt like years.  I wrote the previous post during one of those years, and I thank every one of you who have sent me such sweet heartfelt thoughts.

Later in the afternoon she dragged herself up–still couldn’t get her hind end to cooperate–and between the two of us, we dragged her into my bed, and snuggled together.  Every once in a while she’d stretch her long neck around so she could clean up my face, and finally when she got some energy worked up, she tried to hold me down to wash me, as if I were her own puppy sniffling and snotting in the bed.

A couple more hours and she wanted to go out and pee, so we went out.  A naughty squirrel decided to tease her by getting way out on a tiny branch, and fell THUMP into the road!  It made such a cannon shot hitting the ground, I thought it must surely have killed itself, but it jumped right up and scampered up the next tree over.

I think this must be how you check for life signs in a Malinois.

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“C’mon, Mom, just let me climb that tree, O.K.?  Just this once, huh?”

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A Malinois isn’t dead until you can heave a squirrel at her and she doesn’t move.

But now she’s all worn out from her squirrel hunt, back in bed exhausted. 

If she’s still alive in the morning (no, I’m not joking here), I’ve decided to go ahead with the surgery.  The biopsy will give us the information we need to first of all know for sure what the problem is, and whether treatment can give her more quality of life (to spend cuddling with me, catching frisbees, and chasing naughty squirrels).

There’s a fair chance she won’t survive the surgery.  But her rapid decline over the last few weeks tells me that her quality of life is getting worse.  I love to snuggle with her, but she should be running me into the ground throwing frisbee, not the other way around. 

Wish us luck.

What goes around

I’ve been on a real down swing the past few days.  I want to blame it on the fact that my shrink insisted that the Lamectil was responsible for certain very unpleasant sensations that accompanied my last “mixed state” decompensation.  He maintains that the Lamectil was “feeding” the high side, causing my usual state of insomnia to become drug-resistant and all the rest of the unpleasantness to become worse.

Well, I don’t know if I agree with him on that one or not.  But my state of un-comfortability being what it was, I was willing to give him the benefit of the doubt and try decreasing the Lamectil.  It seemed to help, I think; yet, given the alphabet soup of drugs that I have been taking in order to quell the screams of my tortured nervous system, I can’t vouch that THAT particular tweak was “the one.”

Anyway.  The point is that I have been in a depressed state for the last few days, which accounts for the sparsity of blog posts.  My diet has spiralled down to ice cream and potato chips, which are really the only things my mouth vaguely desires.  I suppose if someone else were to prepare me a delicious AND kosher meal I would eat it; but I can’t guarantee that I would be able to tell you what it tasted like, because when I’m depressed my taste buds go on vacation, along with all the rest of my senses.  If it wasn’t such an unpleasant feeling, I might go, “Oh, just what I needed, a little vacation.”

Luckily I have kept on doing this for such a long time, I’ve come to understand that if I just keep on keepin’ on for long enough, I WILL feel better.  I hope. Or at the very least, I’ll feel DIFFERENT.  Which is in itself a kind of relief.  And I have started taking more Lamectil.

The main thing is to keep. On. Breathing.  One breath at a time.  Because, you know, sometimes “one day at a time” is way, way too much to bear.

Now there’s something I want to say that just doesn’t seem to want to come out just the way I want it.  So I’ll start this way:  to those of you who have sent me heartbreakingly beautiful emails, sharing their responses to things I have written here, I want to tell you that your words have lifted me up and given my heart the will to keep on taking its one breath at a time, one heartbeat at a time.  I could never have dreamed that anything I would say would affect anyone so deeply.  I am awed and yes, frightened by the prospect that anyone would take my words to heart, or that my own experiences would resonate so profoundly.

Yet, in reading your emails, both posted here and sent privately, I have found myself also deeply moved, sitting here pouring tears, resonating with your experiences as you did with mine.

So I think there might be something to this sharing thing.  We can lift each other up on the wings of eagles.  I bless you all.