abortion country II

"Do you think it's a miscarriage."

I purposely avoided her eyes, leaning over to fasten the tourniquet.

"Well, it's... something we have to consider, given the history."

18 year old female, approximately 12 weeks pregnant, one week history of lower abdominal pain and sudden onset frank PV bleed today.

"I mean, I know you're not allowed to say... but do you think it is one? I think it is."

Gravid 2, para nil. Elective termination September 2017. 5 foot tall with large mousy eyes and an angular nose, she was small in a way that somehow also managed to be lanky. To me, she seemed younger than 18, which is to say that if you were to rank her on a bell curve in terms of phenotypical precocity, specifically with regard to the estrogen dependent secondary sexual characteristics relating to mammary glands and fat redistribution, her spot would be somewhere in the lower centiles, which is to say that to me she looked like a kid. She looked about as adult as she probably felt right then - no longer a girl, not yet a woman.

I could tell she had steeled herself for the ordeal. I pictured her, after the initial panic, riding the ambulance in silence, surveying her predicament with a growing resolve. Throughout the history taking, she displayed a good-natured equanimity I had come to associate with the older patients, a calmness that comes from acceptance.

When she said, "I think it is," I looked up from the tourniquet. A lot of times, the answer to 'how should I respond' is 'what does the patient need to hear' and the clues typically tend to reside in the face and the eyes. Does she want for me to deny or corroborate? Does she need the honest truth or a well-meaning platitude? Which will cause the most harm? Which will do the most good? But I saw no pleading or desperation or bravado in the face that accompanied the statement. Only a gentle resignation. The declaration was simply that, a confession with no expectations, with no reciprocal obligation.

I turned my attention back to the tourniquet. "Well, I think... You know... we'll - we'll see what the gynaecologists say... but, you know, it is something... we do have to consider."

She was quiet for a moment, then looked away. I winced internally, wanting to give her more than 'who knows', and having basically told her, 'well, it isn't not a miscarriage'. But it seemed that was enough for her. She withdrew again into her resolve and then only asked innocent questions about blood bottles and being a doctor.

Minutes later, we sent her up to the gynae ward to be assessed. Would it have been kinder just to say, 'in all likelihood, it probably is a miscarriage'? For one, I wasn't clinically experienced enough to be certain of the diagnosis without a scan to confirm. And even if the diagnosis were certain, I wasn't equipped with the knowledge, wasn't in the right setting or frame of mind, hadn't practiced the magic words to counsel her on what it meant, what to do next or how we could support her.

In medicine, you sometimes find yourself in situations where it is your privilege and duty to break news that is life changing. Sometimes it's good. 'The operation was a success.' 'Congratulations, it's a boy.' Sometimes it's not so good. 'The biopsy results have come back, and I'm afraid it is not what we hoped it would be.' Sometimes the best way to break bad news is to let someone else do it.

In a year's time, I wonder if she will remember that cloudless day in May, the one she spent in hospital. In ten years' time, she will recall having a miscarriage when she was 18, and it will be an indelible part of who she is - a part of the bedrock for the house that she calls herself - and my microscopic role in it will likely have been forgotten.

Likewise, I will forget what she looked like, what we talked about, how I felt about the whole thing. But maybe some of it will have made a difference. Or maybe what you say doesn't matter at all. Maybe it gets swallowed up in the tide of everything else that happens. A kind word. A comforting hand. Can small acts of kindness make any kind of lasting difference? Is it metal in a broken bone, that stays in and supports their weight forever, or is it just honey on a dressing, covering over a wound temporarily to help it heal.

As you begin to age, you begin to lose friends, hair, family members, bladder control, memories, and you begin to realise that life is as much about what it gives to you as what it takes away. The day you find out you are pregnant. The day you find out you aren't any more. These landmark moments form the raw material, the minerals and marble out from which you get to carve meaning and identity. And as life gradually stops giving, and starts taking more and more, you begin to understand that life is also about finding yourself in quarries sometimes, and trying to give each other good marble to work with, even if it's just a pebble.