From Sunday’s Washington Post; a pro-choice medical student confronts her abortion “choice”:
On the day of the workshop, Christina wiped out the stock of papayas at a Whole Foods store. The man behind her at the checkout wanted to know what she was using them for.
A medical procedure, she told him.
Come on, tell me, he pushed. A suture?
Something like that, she said she responded. She was not about to get into an abortion discussion in the supermarket.
Bizarre as it might seem to perform an operation on a papaya, in medical school it isn’t unusual. Fruit or other food is regularly used to describe things in obstetrics. A uterus holding an 8-week-old fetus is the size of a naval orange. After 12 weeks, it is more like a grapefruit. The uterus itself is shaped like, well, a papaya.
Lesley’s eyes were drooping as she, Christina and Regina set out tortillas and taco fixings in a second-floor classroom and assembled papayas and abortion instruments at stations in a lab next door. Like the others, Lesley was recovering from a big test earlier in the week, but she also had overextended herself on the treadmill. Still, in a long-sleeve, black scoop-neck top, jeans, shiny black rain boots and a tan sweater vest tied lightly at her waist, she was a picture of elegance. Her chin-length blond-streaked hair was tied into a tiny pony tail, accenting her angular features.
“This is so cool,” said Lesley, who believed she was doing something important to address the shortage of abortion doctors. After years of defending abortion rights, she would finally learn how the procedure is done.
Ten women and three men showed up for the workshop, fewer than the organizers had expected. After heaping their plates with food and chatting about the recent test, the students cleared the lab tables for the teaching doctor to lay out her equipment and pass around photocopies of her lecture slides. Her tray contained a pair of scissors with a sharp tooth on each end, for grasping body parts during surgery, called a tenaculum.
The doctor gave a short lecture on first-trimester abortions. Then she showed the students how to grip the papaya with the scissors to hold the angle of the “cervix” straight on. With one hand, the doctor demonstrated how to administer a local pain killer, at 3 o’clock and 9 o’clock positions. She picked up different sizes of dilators used to widen the cervix and advised against pushing them in too hard, because in a soft-skinned papaya, the dilators might come out the other side. In a woman, more pressure would be needed to slide the dilator past the cervix and into the cavity of the uterus.
The doctor next picked up the suction instrument, a manually operated vacuum suction syringe. It was attached to a cannula, or thin tube, that she inserted into the papaya. She rotated it around the fruit’s cavity, pulling and pushing the syringe, suctioning the papaya’s contents.
“This is the most important thing and the hardest to learn,” the doctor said as she pulled out lots of seeds and juice, what in a real abortion she called the “products of conception,” or POC. “You put the POC into a bowl, repeat if necessary, and examine them under a microscope to make sure you got everything,” she advised.
There was silence as she passed around photos of a dish with a light under it from a real abortion. It contained something that looked like a cotton ball, a yolk sac, and some blood and tissue. It was hard to make out any parts of a fetus under 3 months old, which, she said, is when more than 90 percent of all abortions are performed.
“How do you know you are done?” a student asked.
When you do it often enough, the doctor replied, you’ll notice a gritty feel as you are scraping the uterus. If not, there is another tool, a rod with a spoon, one side sharp as a knife, to scrape again.
Now it was the students’ turn to try the procedure in the lab next door. Imagining herself working on a real woman, Lesley looked tentative as she pushed up her sleeves and reached for the razor-sharp tenaculum.
“This just seems so awful,” she exclaimed as she tried to grab the papaya with it. “Do [patients] feel this?”
Her look turned to fright when the nurse practitioner at her station answered that they do.
Why not apply the local anesthetic before gripping the cervix with the sharp instrument? Lesley asked. The answer: A doctor needs something to hold the cervix steady to administer the drug.
Lesley offered Christina the suction instrument to try first, and Christina took it without hesitation. “You can feel once you get into the hollow part,” Christina told Lesley.
When Lesley’s turn came, she ignored the directions and numbed the papaya before using the scissors. Then she gripped the papaya with the scissors, dilated it with the instrument in her other hand, and suctioned it with the vacuum, twice bringing up lots of seeds and pulp. Finally she tried the curet, the spoon with one sharp side, and pulled out still more pulp.
“So,” she asked the nurse, “did we not suction correctly, or is this a papaya issue?”
“It’s the papaya,” the nurse replied.
The whole thing was over in less than three minutes, but Lesley had plenty of questions.
“Do you feel you have to distance yourself emotionally from your patients?” she asked the nurse practitioner.
“No,” she answered.
“Are patients sad? Upset?”
“Many times they are sad,” the nurse said, but also relieved. “They have made up their minds.” Some cry afterward, she added. “I tell them it’s normal to grieve. It’s a loss.”
“Do they ask you, ‘How can you work here?’ “
“I tell them, ‘I meet wonderful ladies like you,’ ” the nurse said.
Lesley bit her lip and tried the procedure again, and this time she asked technical questions, all the while thinking of what she might say to the patient, how she would explain what she was doing.
On her second try, she perforated the papaya, but she knew the fruit was far softer than a woman’s uterus would be. She put down the instruments. “Now I know how to do one, I guess, if I needed to,” Lesley said.
But she seemed to be harboring reservations about the procedure. She thought using the tenaculum was barbaric: “I don’t know, insensitive. You’d think there’d be something else besides digging into the cervix with a toothlike instrument.”
She tried to rationalize her reaction. Second-year students were only beginning to learn procedures. She had put in a catheter the previous week and had watched a doctor intubate a patient or, in her words, “stick a blade down someone’s throat.” The lack of gentleness by some doctors disturbed her. She knew some chose not to use the very sharp instruments in abortion procedures, but those tools gave the doctor better control and, ultimately, the patient better care. Seeing it for the first time was “jarring.”
Her first surgery was jarring, too. Maybe after seeing it a thousand times, she said, “I’ll get used to it.”
It was during her time in the outpatient clinic that Lesley got to see her first abortions. OB students had a mentor they were supposed to shadow, and one of Lesley’s friends had spent a day with a doctor performing abortions. The friend had held the instruments for part of the procedure, but when the doctor handed her the suction instrument, she couldn’t do it. Lesley wondered what her own reaction would be. She asked to follow the doctor, too.
Most of all, Lesley was interested in the state of the patient. Would the pregnant woman be calm or crying? And how would the doctor deal with those who were emotional? What was the dynamic between patient and doctor?
“Everyone talks about the context, the morality, the politics of it,” she said the night before she would observe an actual abortion, “but nobody really knows what it is like in that moment between doctor and patient.”
She reported at 8 a.m. and met the doctor, whom she described as friendly but gruff. The nurses joked with him, she observed. And when she asked what she would be doing, she said he teased her, “I don’t know what you’ll be doing, but I’ll be doing procedures.” He got up and walked down the hall. Lesley whipped on a gown and gloves and ran to catch up with him.
In the procedure room, the patient had been sedated, but her eyes were open. As Lesley watched, the doctor grabbed the tenaculum, numbed the cervix with a needle, grabbed the specula for dilation, then the suction machine. He was methodical and very fast. The patient was in obvious pain. Her screams gave Lesley the chills, and she thought she might throw up.
“I’m getting dizzy,” she said aloud. The doctor told her to sit down. She backed away, found a bench and sat. She was hot and sweaty.
The procedure took five minutes, and when the doctor was done, he took off his gown and threw it into the trash. Lesley apologized for being squeamish. “I don’t want to seem like a baby,” she said she told him.
He started to ask if she was “one of those who don’t agree” with abortion, but before he could even finish the question, she interrupted. “No, no,” she said she told him. “I’m one of the Medical Students for Choice. I’m not one of those.”
The second procedure was easier. This time the woman had fallen asleep from the sedative. Lesley’s stomach was stronger now. “I can take it,” she told herself. The doctor put Lesley’s hand on the instrument, his hand over hers, and she let herself be guided by him, using the dilator, the suction machine and finally a metal loop for scraping the uterus.
The abortions were over by 10 a.m., and for the first time in her obstetrics rotation, Lesley did not want to leave. She asked to stay, and she spent the afternoon following a nurse practitioner as she counseled and prepared patients for more complicated second-trimester abortions the next day.
“What about the women who come in distraught?” Lesley said she wanted to know.
A woman crying was a red flag, the nurse replied, and she’d gently ask if the woman wanted to go through with an abortion.
The only woman crying that afternoon was one who was too far along to have an abortion and was sent away. Lesley helped with that ultrasound and saw the fetus moving. It was 20 weeks, 3 days old and “pretty real” to her. In previous weeks, she had tried to keep similar-sized babies alive. This “conflict of effort” was, to Lesley, “weird, even surreal.”
Another patient, whom Lesley dubbed “the faker,” tried to use a false name and was told to return another day. A third patient, a 23-year-old college student wearing red high heels, had become pregnant because the patch she used as birth control kept falling off. She didn’t realize she was pregnant at first. Now she needed a second-term abortion. Lesley was struck by how resolute the young woman was. She was earning a degree, and said she couldn’t care for a child if she wanted to achieve her goal. She was scheduled for the procedure for the following morning.
Lesley was free early the next morning and phoned the doctor performing the abortion to ask if she could attend. The doctor hesitated, according to Lesley.
Are you sure? the doctor asked. It’s really hard to watch.
Yes, Lesley answered, she was sure.
The next morning, Lesley arrived at 7:30. The woman with the red heels asked for a printout of her ultrasound and wanted to know the sex of the 14-week-old fetus. It couldn’t be determined.
This time, the procedure took 10 minutes instead of five. The dilator was bigger; there was more tissue to remove; and the patient, although sedated, was awake and moving with discomfort. Lesley watched as the doctor counted the parts of the fetus, and, to her surprise, she didn’t find it jarring. To her, the parts appeared doll-like.
“It was definitely gruesome,” she said. “You could make out what a fetus could look like, tiny feet, lungs, but it didn’t look like a person.” She knew this abortion was an act that her friend Litty considered tantamount to murder. She herself expected to be very upset. She’d felt that way at her first autopsy, that of a teenage boy who’d shot himself in the head. For weeks, she could not shake the image of the boy. But this was different. She didn’t regard the fetus as a person yet. She said she was happy to help the woman: “I feel like I was giving [her] a new lease” on life.
Later that morning, though, while conducting a pelvic exam, Lesley noted that she wasn’t her usual slow, gentle self. That evening, discussing the second-term abortion with her mother, Lesley described a process that she found disturbingly brutal, especially the stretching of the vagina.
“It’s a lot more invasive than I thought,” she said. “A papaya doesn’t bleed and scream.” Women do.
Lesley didn’t want to have to steel herself emotionally to perform abortions, and she was coming to realize that that’s what she’d have to do.
Midway through the piece, a medical student for choice says, “The doctor was probably treating abortion like any other medical procedure, to take away the stigma, the emotional charge associated with it.” The obvious takeaway from the piece — at the heart of “the conflict of effort” is: It’s not just another medical procedure. In most medical procedures your goal isn’t to end a life.