The Baby in the Sugar Walls

It's about 4 a.m., I'm on my fifth latte, and I STILL have yet to plume through the myriad of post-operative hysterectomy charts and round on the gyn patients upstairs and pull out their post-op vaginal packings (a/k/a "vag packs," kind of like fanny packs). My pager (again) goes off, and it's the pediatric ER.

(Note to pre-meds: you better be SURE you want to do this before you invest 175K into it.)

Sigh. Add another consult on my list of things to do before 6 a.m.

I pick up the phone and dial the number.

"Peds ER," says an unnamed voice.

"G-Y-N returning a page," I say.

"Hold please." The Girl From Impanema muzak is playing along lightly while I'm on hold. After thirty seconds of it, I'm humming along, suprisingly in a somewhat better mood because of it.

"Hello gyne?" says someone on the other end.

"Yes."

"I have a consult for you."

"I know." (rowr, kind of bitchy of me.)

"She's a 17 year old girl, pregnant, vag bleeder." (Nice of the resident on the other line just to ignore my 4 a.m. bitchiness and let it go.)

"How many weeks along is she?" I ask.

"About six weeks according to the date of her last menstrual period."

"How was her exam?"

"Non-focal. Abdomen is benign, no blood in her vaginal vault, cervical os is closed."

"Thanks," I said. "I'll be down in a minute."

I grab my coffee and take the elevator down to the peds ER. Unshaven, sweaty and gross, I drag my feet as I walk in.

"Good God," said one of the nurses, "you look awful."

"Gee, thanks," I said.

"Seriously, you look sick. You're so pale and skinny!"

"At least you think I'm thin," I said.

"Really, are you sick? The bags and circles under your eyes are HUGE."

"OKAY," I retorted, "I get it. No, I'm not sick. Actually, yes I am. I'm sick of these 30-hour shifts. I haven't eaten anything but coffee in the last 12 hours. Now where is that patient I'm here to consult on?"

"Room 10. Now here's a bagel."

"Thanks but no thanks. I just want to get this over with."

So I walk into room 10, and I saw this giggly seventeen year old, seemingly without a care in the world on her face. Already I'm upset that she appears so well and healthy, yet for SOME reason decided that 4 a.m. would be the best time FOR HER to waltz into the ER. She's chatting away on her cell phone while her cousin is sitting with her doing the same thing.

"Excuse me," I interrupted, "I'm the doc from ob/gyn."

"Hi doc!" she's grinning ear-to-ear. For some inexplicable reason, I just want to slap that smile off of her face. First do no harm, first do no harm, first do no harm.....

"What brings you in at 4 a.m.?"

"I'm pregnant."

"For how long?"

"About six weeks. And I've been bleeding 'down there' for two days now."

She proceeds to tell me that she's been having vaginal spotting -- not frank bleeding, per se -- for two days, but no other associated symptoms. I scan her chart and see that her vital signs are completely fine, so there's no issue of hypovolemia or bleeding too much. We go through her medical and obstetrical history, and she tells me that this is her fourth pregnancy. At seventeen years of age. Her first pregnancy was at fourteen, and every year since then she's been pregnant. And every year she has aborted each one.

I became very angry with her. I'm pro-choice, but as with all liberties, there are abuses. And this girl -- hardly a woman -- fit every stereotype: young, obnoxious, pregnant, drinks alcohol while pregnant, never tested for STDs, and was using abortion as a form of birth control. And her mother was in the waiting room. Whether her mother was involved in her life or not was essentially irrelevant from a legal standpoint -- a minor becomes emancipated from a medical standpoint as soon as she becomes pregnant.

So I explained to her what would happen: a speculum exam, bimanual exam, then an intra-vaginal ultrasound probe to do a sonogram of the uterus and ovaries and look for the pregnancy to make sure it's intrauterine and not ectopic.

I move to put in the speculum very gently.

"OWWWW!!!" she screamed, holding her friend's hand. "It HURTS."

"Sorry," I said, "I'm being as gentle as possible."

After three more tries, and three more times of her tensing up, protesting, squirming, I got fed up. I'm human, especially at 4 a.m. This girl was SUCH a drama queen.

"LOOK," I told her, "This is your FOURTH pregnancy, and from what we've already talked about, you've had plenty of sex over the last few years. This speculum is quite smaller than the average penis, so don't tell me you can't do this."

I know how many of you readers are gasping right now. Maybe your technique is wrong, you're thinking. Keep your thoughts coming, I know they are one of the following criticisms of me:

You're such a paternalistic asshole to this poor little girl.
You don't know her home situation, maybe she's being abused and/or raped, and THAT'S why she's pregnant.
You're so insensitive.
You've never had a speculum exam, how would you know what hurts and what doesn't?
You're so inappropriate to say that to her.
You're a male in a male-dominated society, you should show her more respect.
Maybe she wasn't having sex per se to get pregnant, the man could have ejaculated around her vagina without actually going inside of her, that's why it hurts.
Maybe she has an STD and this exam really hurts her.
She really needs you to LISTEN to her and be more humanistic towards her right now, this is very tough for her.

Now, here's what you should do: take all of those overly-p.c. thoughts, write them on a piece of paper, them crumple it up, reach around to your backside, and push it deep inside your own asshole.

I don't think I should have to defend myself, but SOMEBODY apparently needs to be more authoritative to this girl and teach her how to respect herself and her own body more than that. Someone needs to help her take control of her life. I'm not that somebody per se, but I think that she probably needed and still needs more discipline, self-imposed or otherwise before she callously throws her own life away to HIV/AIDS or God knows what else.

But yes, I get it, that isn't exactly the most appropriate thing to say. It was 4 a.m., I was overly stressed, overly worked, overly annoyed. But really, isn't what I blurted out essentially true?

Regardless, after I scolded her, she shut up, we did the exam, and she didn't complain that it hurt at all anymore. In fact, she indicated (verbally and otherwise) that she was quite comfortable the whole time.

I did the ultrasound exam and showed her and her friend a picture of this tiny bubble inside her uterus.

"That's your baby," I said.

"Awwww....." she cooed.

We finished up, and I told her that she had a viable pregnancy in her uterus, not a tubal one that would have to be terminated.

"Here's the clinic number for follow-up," I said.

"Thanks. Is this the number where I can get an abortion? I think I want to get rid of it."

My face turned red. "This is a general number," I told her. "From here, you can either make an appointment for prenatal care and testing, or you can get an abortion. It's your choice and I support your right to choose, but to be honest with you, I think you're being irresponsible."

Gasp. In this day and age, can a doctor talk to a patient like that?

I think yes. Very often, the medical establishment is levelled with criticism that we're too paternalistic, that we tell people what to do, that we think we know what's best for someone.

Isn't that why we go to medical school? Isn't that why we become doctors?

I argue that we DO know what's better for you and it's our job to explain those choices to you and what they mean. It IS paternalistic, but it's designed to be that way. I never tell anyone what to do, but I have my advice. No, you shouldn't eat so much red meat, but is it paternalistic to instruct a patient not to do that? In this era of choice, should I not tell people what those choices mean and help them make a decision? I understand that I'm human too and that I may make mistakes or that I may not know everything and that I too have unhealthy habits (like staying up for thirty hours in a row), but I posit that I certainly know more about medicine and healthcare than 99% of my patients and I should tell them what their choices are and what those choices mean for them.

"What do you mean, irresponsible?" she said.

"I mean this: you're seventeen, this is your fourth pregnancy, and you're using abortion as a form of birth control. You can do what you want, but you need to remember that your actions have consequences. When I say you're being irresponsible, I mean that you're sexually active at a young age, you've never been tested for STDs, you have no idea if you have HIV or not, and you're letting men take advantage of you sexually. I think you should respect yourself more than that and take better care of yourself and take more control of your life. I sound like your father, but I'm not and I don't want to be. These are your choices to make, and I think you should be making smarter choices."

"I see," she said, eyes downcast. "No one's ever said anything like that to me before."

"Well I think it needs to be said," I told her. "Now, do you have anymore questions before you're discharged?"

"Yes," she said. "Can I make another appointment with you? I'd like you to be my doctor."

Something clicked inside me and I wasn't mad anymore. Instead of seeing her as an irresponsible brat, I now thought of her more as a misguided teenager who was unaware of the opportunities that she had. Perhaps her parents had never taught her the value of a good education, perhaps men sent her the message that she was only worth something through sex, or both. And I'll admit -- yeah, I felt a little flattered by the encounter, that she felt like she could trust me with so much information and care after only fifteen minutes.

I explained that I didn't have clinic hours, but she should make an appointment soon to see someone about getting proper testing and care for herself. She agreed to get testing for HIV and other diseases, and to start seeing a physician regularly and getting pap smears.

I recently checked her medical record number in the computer, and as it turns out, she had in fact gotten all necessary tests and had a appointment for a pap smear. As for the baby, however, I really have no idea if she had an abortion or not. If I'm not her primary doctor, then I think that that is not my business. It is, after all, as I explained to her, her choice to make.