Week Three

WARNING!
FOR MATURE READERS ONLY

I feel that it is important for me to blog about my week, however, due to the sensitive nature of the clinic I've been in this week, I feel it is also important to alert my readers.  To preface this entry, I have left out all personal and political perspectives because the root of the experience has been about medicine and treating patients.  So without further introduction, this week my clinical rotation was in the T.O.P clinic... or in other words, Termination Of Preganacy.

In South Africa it is legal to perform abortions up to 20 weeks of gestation.  There are only three doctors in all of Cape Town who perform the abortions (they are all female doctors), and they rotate through both the public and private hospitals.  As with other medical services, GF Jooste is popular location for TOPs and accepts referrals from other community hospitals.  In summary, here is break down of the week:

Monday & Tuesday: up to 35 patients are accepted into the TOP clinic for screening and counseling.  The patients must present a referral letter from their community clinic or general practitioner - this letter alone can cost the patient 200ZAR (about 30USD) which is a steep fee, especially when the cost of all other visits is free.  The patients are accepted first come first serve, so they arrive between 06h00 and 07h00 even though the clinic hours do not officially commence until 09h00.

Everyone is poked and tested for HIV (I helped perform the testing), then brought back one by one for the results and counseling based on their status.  Then all of the patients file into the "theater" room ("theater" is the South African term for operating room/OR) where there is one table separated by a thin curtain.  The patients get onto the table for a quick ultrasound to determine the size of the fetus.  The doctor spends only two to three minutes per patient before they are rushed off the table and back to the waiting area.  I actually got to perform a couple of the ultrasounds, which was a good learning experience.

The group is then divided by weeks of gestation: 6-12 weeks (first trimesters) are given an appointment on Wednesday or Friday for the TOP.  When they return to the clinic they will take Cytotec to help open the cervix for the procedure.  13-20 weeks (second trimesters) are counseled seperately, and are given Cytotec tablets to take at 03h00, 05h00, and 07h00 the morning of the procedure.  Everyone is instructed to bring their own towel and feminine pads - nothing is provided for the patient.

Wednesday, Thursday, & Friday:  first trimester TOPs are done on Wednesday and Friday, with second trimester TOPs reserved primarily for Thursday.  The patients arrive by 07h00 to take the Cytotec; when I arrived at 08h00 some of the girls/women are already bowled over from cramping side effects. The doctor arrives by 09h30 and no time is wasted to get started.  The girls/women are arranged in rows of chairs just outside the theater, seated from earliest gestation to latest. They are instructed to remove all clothing below the waist, and so they sit wrapped in their towels waiting for their turn.

Several of the patients abort before they even make it to theater, and so there is a constant flow between the chairs and a (very) small toilet in the room.  When this happens a nurse is called from theather and the patient is given a small paper bag (like a barf bag) to put the aborted contents in.  Mostly though, the girls/women move perfunctorily into the theater area for the TOP.  It is a quick, albeit gruesome, procedure; about five to ten minutes for first trimesters (who get no local anesthetic), and about 15 minutes for second trimesters (who get 20mls of lidocaine injected into the cervix).

When the procedure is completed for one patient, she is rushed off the table and wraps in her towel quickly before the nurse yells "Next" for  the next girl/women to enter. And so it continues until all of the girls/women have been treated.  Wednesday I was in theater for five and a half hours straight and Thursday there were 24 TOPs before noon.  When I use the term girls/women it is to encompass the full spectrum of patients seen; the age range this week was 13 to 39 years old, with everything in between. Many of the women are married and a majority of the patients used some type of birth control before becoming pregnant.
In total, it was a very profound and emotionally exhausting week.  As an outsider, I felt that there was a lapse in the birth control education as well as the counseling that occurs before the TOP.  For example, the patients are counseled that even if they are taking the pill that they are not protected from HIV and so they need to use condoms, but then the sisters (nurses) really push for the patients to get the contraceptive injection (which still doesn't protect against HIV)... so the output is a very mixed message.

I learned a great deal from the physicians this week and my heart was heavy for the patients that I worked with.  I've seen things that words cannot even begin to express and I have been racked with how to process everything that I've experienced and felt.  What it comes down to is this: is it any different than a patient who presents with lung cancer after a lifetime of heavy smoking? doesn't that patient deserve to receive medical treatment if they choose it? and shouldn't the medical care be delivered with compassion and without judgement?