Category Archives: Health Care

Health care system discussions

Saga Redux Part 2

9 Replies

The CT simulation takes anywhere from twenty minutes to an hour. The patient lays on the table and the body area being treated is immobilized with either a mask (for head and neck) or a Vac-LokTM cushion filled with Styrofoam beads. When air is removed from the cushion, it creates a unique mold, so that the patient is in the same position for each treatment. The tech also marks the target area with tattoos, guided by laser beams across my abdomen.

They gave me these instructions to follow before my simulation appointment:

I’m not sure how many people are able to empty their bowels and bladder on command. Everyone’s physiology is unique, so generic instructions like this should be taken as suggestions, not dogma. I used a disposable enema in preparation for the simulation and drank water as ordered. CT appointments were running late, and I had to cross my legs by the time the tech called me.

“Is your bladder full?”
“It’s more than full. My teeth are floating.”
“Well, you’re going to have to hold it for at least 20 minutes. Do you think you can do that?”
“Oh, hell no!”
“Well, empty your bladder a little bit but not too much.”
That’s easy for you to say…

The CT simulator room was down a long hallway past steel double doors and far from the treatment rooms. The tech placed what looked like a heavy, vinyl sleeping bag on the bottom half of the simulator table before I lay down. A few minutes later I felt the Vac-LokTM bag harden around my legs. The tech left the room after all was set, and all I had to do was lie back and think of England for the next 20 minutes.

When the scan was finished, she made three cross marks with an ink pen – one in the middle of my lower abdomen and one near each hip – and covered them with waterproof tape. I’d get permanent tattoos at my first treatment. Before I got off the table, she took my picture with a small digital camera. My DMV mugshot looks like a Rembrandt portrait in comparison.

A radiation physicist and/or medical dosimetrist uses the information acquired by the scan to calculate radiation doses, precise target locations and the number of daily treatments required. This can take a few days or a couple of weeks. (I also think they use the time to ensure treatment is covered.) Treatment starts after the radiation oncologist approves the plan.

I got the call on January 24 to start treatment the following Monday.

The Radiation Oncology treatment center runs about 80 patients through two rooms every day. New patients are fitted into available slots for the first week or two; they get a regular appointment time as other patients complete their treatments and leave. My appointments were anywhere from 1:15pm to 4:15pm before getting a 12:30 slot at the end of week 2. This was a great time because there were more available parking spots near the entrance.

On Monday I arrived 15 minutes before my appointment only to find my first treatment session was cancelled because of some issue with the machine. Carla explained someone had called me, but I didn’t recognize the number and had ignored it. (Note to self: add important number to your contacts.) She assured me their technical people were working on it and I should be able to start the following day.

Peg had gone into work, so she called to ask for an update.

“So how did your first session go?”
“It didn’t. The machine was broken.”
“What happened?”
“Well, it got stuck and the guy who was in there got a massive radiation dose and he exploded all over the place. There are guts on the wall, and they had to bring in a hazmat team to clean it up.”
“WHAT? Oh my God!  That poor man! I can see where they’d need hazmat with all that radiation…Wait, did that really happen?”
Me snickering on the other end.
“You’re an asshole.”

On Tuesday Radiation Oncology called me just as I was getting ready to leave.

“We’re still having problems with the machine, and they are waiting for a part.”
“What, STILL??? So, I’m going to have to wait another day?”
“No, we are trying to work people in. Can you come for a treatment at 4:15 today?”
“Yeah, that will work.”
Not as if I have a choice.

Peg was livid when I told her.

“It’s not a problem for you; you’re retired, and it’s only a 15-minute drive for you. What if it was someone who was working and had to arrange time off? Or someone who had to drive 30 or 40 miles to get to their treatment? If we have a problem with our computer system, someone is on it right away! If this is going to be a regular occurrence, we might have to think about going to one of their other facilities that is more reliable for your treatment!”

Carla took me back to the treatment area for the first time and showed me the locker room. After that, I was allowed to pass GO and head back on my own. There were separate locker and waiting rooms for men and women, not unexpected since most patients wore hospital gowns to expose their treatment areas.

The flat-panel TV on the wall drowned out the overhead speaker playing classic pop music from the 1960s to the 1980s, appropriate for our ages. There was a rotating collection of old guys in the waiting room during my first week; we recognized our arrivals with nods or grunts while watching Bonanza and Rifleman reruns. Several times one man sat in the corner reading a book. I assumed he was there supporting his wife since no one ever called him back for treatment.

Mostly we kept to ourselves, but one day an older man started talking to me about his disease. I wasn’t sure what to say so I just listened.

“I had prostate cancer and now it’s in my bones. They did this procedure (therapeutic plasma exchange) where they take your blood out and clean it and put it back in and that’s helped a lot with the pain.”

He seemed far less upset than I might have been, but maybe that’s part of getting older. You’re resigned to the things you can’t really change and just hope the eventual end isn’t terribly painful.

I couldn’t have any metal (rivets, buttons, zippers) near the treatment zone, so in the beginning I changed out of my jeans and put on a hospital gown. By the third week I’d learned to wear sweatpants and slip-on shoes after seeing another guy wearing them. One might figure they’d make that suggestion to patients, but one would be mistaken.) I’d toss my jacket, car keys and shoes into the locker and was ready to go.

I played around with the amount of water and the time when I started to drink. I learned not to eat a Reuben just before drinking because the fat slowed down water absorption. I tried drinking a lot more than usual to get my bladder to fill, but I paid the price when I peed like a racehorse for a couple of hours, long after my treatment ended.  

I started wearing Depends because it was difficult to fill my bladder enough to keep the techs happy but not so full that I might leak. One time the tech, a young guy probably in his 20s, told me my bladder wasn’t full enough and I should drink more water before the next treatment. (That’s easy for you to say.)  I’d gotten the sudden onset of explosive diarrhea right before my session and unless I clamped the hose with a chip clip, my bladder was going to be on the dry side.

My routine: Every day the techs call my name and escort me to a long desk on which sat several computer screens. Each time they ask for my name and date of birth, which I think is a bit silly. They know my name, my picture is on the computer screen, and I can’t imagine why anyone would sneak into radiation treatments for the hell of it.

There are three large signs above the entrance – HDR, BEAM and XRAY – which illuminate depending on which process is active. The department uses high dose radioisotopes (HDR) such as iodine-131 (I-131) for treating thyroid cancer. I’m getting Intensity-Modulated Radiation Therapy (IMRT) which uses higher doses of x-rays (BEAM). XRAY lights up when doing a CT scan, a much lower dose, before treatment.

I walk in past a 10” thick door filled with lead and into a lead lined treatment room.  When I told Peg about the lead, she said, “See! The chances of a disaster are low but not zero!”

The star of the show is the Varian TrueBeamTM Linear Accelerator. The kV x-ray generator and flat panel detector are at 3 and 9 o’clock. The Electronic Portal Imaging Device (EPID) is at 12 o’clock. The linear accelerator treatment head is at 6 o’clock.

I drop my pants and jump on the table, putting my legs in the Vac-Lok mold. They ask if I want a blanket, but I decline because it’s warm in the room. They are quick to cover my nether regions with a pillowcase, but I think it’s for their peace of mind more than mine. Old man penis, like its owner, is tired and not much to look at. Laying on my back is uncomfortable. I’m trying to keep my bladder from leaking, and my right shoulder hurts when I put my arms above my head. I just want to get it over with.

They raise the table and push it towards the machine. They still need to adjust my body by yanking on the sheet beneath me. “Pull a quarter.  Pull a half. Pull one.” When the lasers are lined up with my tattoos, they leave the room. I hear the door creaking as it closes, and I wait.

The CT parts move into position. The machine then makes a single smooth rotation and forms a CT image of my pelvis which appears on the computer screens at the desk. Then the tech compares a digitally reconstructed radiograph (DRR) with the scan for fine alignment. The scanner parts are moved back to their resting positions, and I wait while things are lined up. Sometimes the tech remotely adjusts the table before the treatment begins.

There’s a dull thud a few minutes later which I assume is the accelerator powering up. A red light on the wall starts flashing. There’s another thud followed by what sounds like a swarm of cicadas as the machine starts to rotate. This time the machine’s movement is a little jerky.  (Dr. Howard told me that happens as the collimators in the treatment head adjust, shaping the treatment beam.)  It makes one full rotation, pauses for six seconds and then rotates in the opposite direction.

Occasionally the machine will stop and beep. They told me afterwards not to worry, because automatic sensors stop it if the sheet got too close, and no, it wasn’t continuing to fry my innards. They had to reboot the computer system during another treatment. You’re sure everything is OK out there?

The machine stops and I can hear the blast door opening. The techs lower the table as I pull up my pants. They remove the mold and help me sit up. I say, “See you tomorrow.” Then I make a beeline for the bathroom.

Every Tuesday they take my weight, and then Danielle escorts me to an exam room and asks me the following questions:

“How are you feeling?”
“Pretty good.”
“Any problem with diarrhea?”
“Not enough to need Imodium.”
“Any problem with urination?”
“Nope.”
“How’s your energy level?”
“It sucks.”
“OK, I’ll tell Dr. Howard you’re ready.”

Some side effects can be debilitating. A friend of ours, who is really skinny, suffered radiation burns to his lower abdomen that were so painful his wife had to drive him to his appointments lying flat in the car. The mother of someone with whom Peg works has to drive 40 minutes to her sessions and sometimes is so tired she can barely get out of bed.

Diarrhea has been the worst side effect. I initially thought it was because I no longer had a gall bladder, but it was much worse than that. The first bowel movement of the morning is normal; after that it’s watery like my colonoscopy prep. I can hear my intestines gurgling and I get sudden urges for the next few hours.

Fatigue has been the most frustrating. I have a long list of things I’ve wanted to do since I retired, but motivation is near impossible. I want to nap all the time, but I fight the urge, which does me little good. I’m still tired and nothing gets accomplished.

Dr. Howard comes into the room a few minutes later and goes over what the nurse has told him. I verify my answers for him, and he says, “You are doing remarkably well. I’ll see you next week.”

During one visit I asked him, “What’s the chance of recurrence?”
“Let me look at your pathology report.”
“Gleason 9 with EPE (extraprostatic extension.”
“Yes…I think we have an 80-85% chance of cure.”

This wasn’t surprising given my tumor was aggressive. If I’m lucky, any recurrence will be slow and late enough that something else will kill me first.

My visits with Dr. Howard are short because I am a physician and not a typical patient. We speak the same professional language and have an intuitive understanding of each other. (Peg says we share “the secret handshake” that grants me access to special courtesies like being released from the hospital three hours after my prostate surgery.)  I’ve had very few side effects and there is little need to spend a lot of time with me.

Lest you think the physician visit is superfluous and merely a reason to charge for the visit, I can assure you it’s not. He or she is monitoring a patient’s progress and needs to be aware of anything that might require altering the treatment plan.

The average patient is likely to be overwhelmed with a cancer diagnosis and subsequent treatment. Nurses have a special role as the intermediary. Patients will often impart far more information to the nurse because “I don’t want to bother the doctor.” They pick up on a patient’s non-verbal cues such as reluctance, anxiety, frustration, or anger. And it’s not unusual for a patient to tell the nurse one thing and the physician something entirely different or contradictory.

I got a garden-variety cold the last week of treatment and I was far more tired than usual. (I suspect it’s because my niece had one the week before me. She is a pre-school nurse, and her charges are disease-spreading vermin who rarely suffer as much as adults with the same maladies.) As I left the treatment room the second to last day I said to the tech, “I’d like to say I’m gonna miss this but I’m not.”

Finally, it was over. I dragged my tired ass out of the locker room and rang the large bell sitting at the desk, signaling the end of treatment. I said goodbye to Danielle and hugged Carla on the way out. The staff was great, and I can’t thank them enough.

It’s been a few weeks since I finished treatment. The diarrhea has slowly gotten better, but I still have a throbbing, painful hemorrhoid reminding me every day. I’m less tired which may be due to more sunny weather as well as recovery.

I’ll get my first post-radiation PSA and see Dr. Howard at the end of June. It probably won’t be down to zero because radiation therapy isn’t like a laser blasting everything in its path. Instead, it kills some cells and damages the DNA of others so those cells can’t replicate. (How Radiation Therapy Treats Cancer-NCI)

I’ll discuss the aggravation of dealing with billing in another post, but the ballpark estimate of charges for my treatment is around $69,000.

Featured image © Can Stock Photo / focalpoint

Saga Redux

3 Replies

In December 2019 I had surgery for prostate cancer after my annual PSA levels, which I’d beengetting since 2007, started to gradually increase in 2017. The surgical pathology report showed my tumor was more aggressive than the biopsies, and even though the resection margins were clear, the tumor had already started to extend beyond the prostate. Radiation treatment for a recurrence sometime in my future was likely inevitable. I would get PSA tests every three months for a couple of years, then every six months if they remained negative or stable. Eventually, if all was well, I’d get annual PSA testing for the rest of my life.

My PSA levels during 2020 were <0.014 ng/ml, below the level the test can detect. The first one of 2021 was 0.015 ng/ml, a very insignificant increase. My levels rose again slightly before hitting a plateau between 0.022 – 0.027ng/ml. In December 2021 Dr. Fine, my surgeon, recommended I get tested every six months. In June 2022 the result was 0.023 ng/ml, and I was relieved it had gone down.

Six months later my PSA was 0.044 ng/ml, almost double the previous level.

I sat at my desk for several minutes, starting at the results on the monitor. Intellectually I’d known this was a possibility, but now it had become reality and I wasn’t sure how I felt. It wasn’t a death sentence and the low level meant I didn’t have a large cancer with metastases. I was more worried about how Peg would react.

“My PSA was point-zero four-four.”
“Ok. How do you feel about that? It’s been a good three years.”
“I dunno. I’m not surprised but I’m not sure what to do next. I should probably ask Dr. Fine what he thinks.”
“Well, I’ll support whatever you want to do.”

Now, back in the good (or bad) old days, before e-mail, smartphones, and websites, I called patients on an antique, corded landline to discuss important issues, like abnormal Pap smears and biopsy results. Now most large health care organizations use MyChart, an application that allows patients to schedule their own appointments, communicate with their healthcare providers, view their medical records and test results and pay outstanding bills, all while adding another degree of separation between patients and said providers.

My health care organization, Suburban Medical Center, is more interested in efficiency and revenue than customer service; their medical providers are tightly scheduled and controlled. They prefer to communicate via email, often after hours or during a rare break.  There are no direct phone numbers to any of the offices; one has to call the generic department number. If I want to talk with a physician’s nurse, the department personnel might try to contact her (usually her).

I sent a message to Dr. Fine through MyChart.

Me: Level has doubled. Now what?
Dr. Fine: Since lower than 0.05, I recommend repeat PSA in 3 months. We can follow it a bit closer. If it continues to rise, we would consider planning for salvage pelvic radiation therapy.
Me: Pelvic salvage sounds like a sunken ship. So is this likely tumor cells, residual tissue or Karma messing with me?
Dr. Fine: Not Karma Salvage RT sounds bad but can provide cure for you. We went 3 years with just surgery which is great for your very aggressive cancer. If you’d like, I can arrange a visit with our radiation oncologist, Dr. Howard.
Me: Only if you think we’re at that point. It seems the experts don’t agree on the threshold; 0.05, 0.1 and 0.2 are the numbers I’ve come across.

Whether to treat or continue monitoring depends on the level and the rate of PSA increase, but in the end it’s what the patient wants to do. Ultimately, I decided that continuing to follow PSA levels would only increase my level of anxiety and delay the inevitable.

I asked the office to set up a referral and ran into my first problem. Someone entered a referral to Hematology/Oncology. I tried the “Find a New Provider” option in the application, but Radiation Oncology didn’t appear on the list. I found Dr. Howard on the organization’s general website but there was no option for making an appointment. Round and round we go.

I thought making an appointment in person would be more expedient, given the office is only a few miles from my house. Carla, a diminutive, cheerful woman greeted me as I walked in.

“My name is Carla. How can I help you?”
“Is this Dr. Howard’s office?”
“Yes, it is.”
“I had surgery for prostate cancer 3 years ago and now my PSA levels are going back up. Dr. Fine suggested I talk with Dr. Howard about radiation. I’ve been trying to make an appointment and it hasn’t been easy.”
“How soon are you hoping to see him?”
“Sometime in January is fine.” (I didn’t want to ruin Christmas with potentially bad news).
“Well, let me see what I can find.” She looked at the schedule for a few minutes.
“He’s got an opening on Tuesday January 10. You’ll meet with his nurse at 8:30am and she will go over a lot of information, then you’ll see Dr. Howard at 9:00am.”

I knew Peg would want to come to the appointments because she cares deeply about my wellbeing and doesn’t trust the health care system as far as she could throw it. She also asks far more questions than I do. I mostly wanted to talk about whether radiation was a good idea, how long it would last and what side effects to expect.

There were several other people in the waiting room on our appointment day. Everyone had to wear masks, but for some people rules are mere suggestions. There was an old guy in a wheelchair whose daughter hovered over him while he took sips of coffee in between hawking up hairballs, sans mask. Why have a coffee machine in the waiting room if you’re supposed to keep your face covered.

Danielle, the nurse who does pre-consult counselling, called us into a room and, over the next 25 minutes or so, gave us an overview of radiation treatments, side effects and how to deal with them, and warning signs like rectal or urinary bleeding. I don’t remember a lot of details; you’d probably have to ask Peg. Having the nurse see the patient first is probably a good idea, especially with elderly patients, given that nurses tend to be far more patient. She gave us a packet of information and left.

A few minutes later Dr. Howard came into the room and gave us a warm greeting. He was a tall, thin bald guy who reminded me of Ru Paul. I shamelessly told him I was a retired physician; that often changes the tenor of the interaction. There’s no need to dance around delicate subjects like clinical judgement, diagnostic or therapeutic uncertainties, disability or death.

“We’re here because my PSAs have gone up relatively quickly in the past six months. Given my tumor was more aggressive than the biopsies and there was extraprostatic extension, I figured we’d be doing this sooner or later. Is there an advantage to doing this now over waiting and following PSAs?”
“I know what I’d do in your situation. Radiation is like battling an army. I can fight against 1000 soldiers or 10,000 soldiers. So, doing it now increases the chance of cure.”
“So, how do you know where you’re shootin’?”
“We direct radiation at the bed where the prostate was. Before treatment we run what’s known as a CT simulation and map out the area. It takes about 2 weeks for the radiation physicist and me to set up a program. We’ll call you when we’re ready to start treatment. You’ll come in five days every week, but initially we’ll be putting you in to different time slots. You’ll have a regular time slot in a week or so as other patients finish their treatments.”
“How long is this likely to take?”
“Usually about 37-40 treatments. We’ll start doing PSAs again in about three to four months.”

I left with an appointment the following Tuesday at 4:00pm for the CT simulation.

Preauthorization

There’s a meme on the Internet that exquisitely illustrates the differences between the American and Canadian health care systems. (Since I don’t know if this is copyrighted, click here to view.)

Breaking Bad Canada
You have cancer.
Treatment starts next week.
END

Just because you have insurance doesn’t automatically mean the insurance company will approve payment without question. They require approval for anything that is likely to cost them a lot of money. Our insurer is very good at authorizing treatment. Other companies make their subscribers jump through a lot of hoops, even for cancer treatment, looking for ways to weasel out of paying. (A friend of ours whose wife ultimately died of her second cancer had to fight for things our insurer would have approved without question.)

Peg works for our insurance company, which stresses the employees are the “first line of defense against waste, fraud and abuse,” and as such are diligent guardians of precious health care dollars. And did I mention she hates the health care system in general?

She called our insurance company to ask about preauthorization for my simulation and treatment. This started a week-long exercise in futility, prompting her to wonder, “How do they manage to open the doors in the morning?”

“I started with one of our care coordinators who was very helpful. I asked about getting a pre-authorization for the CT simulation and therapy and how much this was likely to cost us out of pocket. She told me Suburban Medical hadn’t submitted pre-authorization requests yet, so she called Linda in Radiation Oncology. Ultimately, they determined there was no need for the pre-authorization for the simulation because it’s not for diagnosis. We’ll need it for treatment, but they can’t provide a cost estimate until after the provider submits a treatment plan.
“So, then I called someone else to try and get a ballpark figure for radiation treatments. He found general cost estimates for prostatectomy and brachytherapy but nothing for radiation. He suggested I call Suburban Medical, which I did but I left a voicemail and haven’t heard back.”

A week later she tried again.

“I called the care coordinator again; she hadn’t gotten a pre-auth yet, even though it’s been ten days since your consult and your simulation was at the beginning of this week. Suburban Medical told her she wouldn’t get any requests until the imaging results were available. It usually takes a couple of days to approve it, but she said she’d fast track it for us before treatment starts.
“I called Suburban Medical but whoever I spoke with couldn’t supply any cost estimates. She suggested I call our insurer back, which I did. Our rep said the provider should have this information easily available since this is their business. He’d need more information because estimates are based on the individual provider, the specific plan and reimbursement contract. He did say, ‘You’re likely to blow through your deductible and out of pocket before this is over.’
“I finally gave up and went to Google. Estimated costs for radiation therapy for prostate cancer recurrence range from $33,000 to $67,000.”

Wow!

I’m fortunate having insight into the health care system as well as a tenacious woman looking out for my interests. Imagine, though, the aggravation and anxiety a person with little disposable income has to endure, navigating through a confusing bureaucracy and wondering how to pay for several thousand dollars of treatment while coping with a cancer diagnosis.

I’ll discuss the simulation and treatment in my next post.

Featured image © Can Stock Photo / bertoszig

Taking the Wrong Way Home

8 Replies

A pregnancy starts when a Fallopian tube sweeps up an egg like a shop vac and sends it down towards an army of sperm lying in wait.  While it takes one sperm to fertilize an egg, it takes hundreds of them to break down the zona pellucida, the egg’s barrier to fertilization.

When that happens, the lucky bastard yells, “I’ve got you now, my pretty,” and thrusts himself into her.  Now joined in holy matrimony, the fertilized egg – a zygote – takes a short honeymoon trek down the tube, developing into a blastocyst on its way the uterus. There it implants, sets up housekeeping and watches Netflix for the next nine months.

But that doesn’t always work that way. The blastocyst may attach itself somewhere outside the uterus in an “ectopic” location that wasn’t designed to grow a full-term baby. Those sites include the Fallopian tube (the most common); the cornua (where the tube attaches to the uterus); the cervix; an ovary or inside the abdomen.

An ectopically implanted pregnancy is more likely in a woman whose tubes have been damaged by infection, endometriosis, or previous abdominal surgery, including tubal ligation.  Using an IUD for contraception increases a woman’s risk. Even a woman who has had a hysterectomy but with an intact ovary can become pregnant, likely earning her a place in the tabloids.

An abnormally implanted pregnancy can only grow so much before the tissue around the implantation site blows apart and all hell breaks loose. Internal bleeding can be massive and a woman will die from hemorrhagic shock if not treated promptly.

The Arab Spanish physician Abulcasis (Arabic name: Abul Qasim Khalaf ibn al-Abbas al-Zahrawi al-Ansari), was an impressive and accomplished dude who wrote Al Tasrif, a thirty volume medical encyclopedia, earning him a place among the “fathers of surgery.” He made the first known reference to ectopic pregnancy in the 10th century. Other physicians reported ectopic pregnancies during the next 900 years, largely discovered at autopsy as it was invariable fatal.

But by the mid 1800’s doctors were becoming more aware of the signs and symptoms of ectopic pregnancy. Timely surgical intervention saved the lives of many women but definitively differentiating an ectopic pregnancy from other conditions – an ovarian cyst, endometriosis, or appendicitis – remained problematic for the next 100+ years.

Such was the state of diagnostic abilities when I started my residency in 1979. A woman who came to the Emergency Room in obvious hemorrhagic shock – high pulse and low blood pressure – went straight to surgery. But if she presented with lower abdominal pain, a positive pregnancy test and sometimes brown vaginal bleeding – and was hemodynamically stable – we tried our best to confirm an ectopic pregnancy. The probability increased if, on pelvic examination, one felt a painful mass on either side of a normal-sized uterus, but there was still a 20% chance it was something else.

Ultrasound had been used clinically since the mid-1950s, but images weren’t great, appearing more like abstract paintings than pelvic organs. Radiologists’ interpretations were often ambiguous and usually unreliable when proclaimed with absolute certainty. One of my attending physicians opened up a woman’s abdomen after the radiologist said, “There is definitely an ectopic pregnancy here,” only to find absolutely nothing.

If we were still unsure and the woman agreed to it, we’d try doing a culdocentesis.  That involved sticking an 18-gauge needle through the back of the vagina below the cervix, then pulling back on the plunger of a large syringe. (Yes, it’s as painful as it sounds, even after injecting local anesthetic into the area.) Sometimes we were lucky. If the syringe filled with “non-clotting” blood (blood that had already clotted and then broken down), we knew she was bleeding internally and likely had a ruptured ectopic pregnancy. If culdocentesis wasn’t successful and we still weren’t sure, we took the woman to the operating room for diagnostic laparoscopy sparing the woman an abdominal incision if everything looked clean.

Tubal pregnancies are usually dark purple blobs, ranging in size from a pomegranate seed to a breakfast sausage, which may be leaking a little blood or actively hemorrhaging. There’s usually a small piece of placental tissue among the clot in the tube, but nothing that remotely resembles a fetus. I witnessed one notable exception during my residency. A tiny, live fetus, about the size of a grain of rice, was moving in the small gestational sac that had been expelled from the end of the tube. And no, there was – and still – no way to implant it into the uterus! Placental tissue, once disrupted, won’t reattach itself in the uterus.

We had three surgical options:

  • Opening the tube over the affected area, emptying out the contents and delicately sewing the incision shut, making sure there was no bleeding. The tissue was fragile and it was like sewing two sticks of room temperature butter together.
  • Taking out the damaged section of tube, leaving the ends for a skilled microsurgeon to put back together later on.
  • Taking out the entire tube because a badly-damaged tube made another ectopic pregnancy more likely.

A lot has changed since I started residency more than forty years ago.

Diagnostic testing

Simple urine or blood pregnancy tests, first developed in 1976 and referred to as “qualitative”, look for the presence or absence of human chorionic gonadotropin (hCG) a hormone produced by placental tissue.  A positive test indicates a pregnancy somewhere in a woman’s body. A negative test usually means there is no pregnancy but the test will be “falsely negative” if hormone levels are too low to detect.

Structurally, hCG is made up of two pieces: the alpha subunit (α-hCG) which is also common to ovarian and thyroid hormones, and the unique beta subunit (β-hCG). Starting in the early 1980s, laboratories were able to assay blood for small amounts of this beta unit, the “quantitative β-hCG test.” We used the changes in hormone level over several days to monitor very early pregnancy development, hoping to distinguish normal pregnancies (single and multiple) from abnormal ones (blighted ovum, miscarriage, ectopic, the varied forms of molar pregnancy, or placental fragments leftover in the uterus after a miscarriage).

Measured in milli-International Units per milliliter (mIU/mL), hCG becomes detectable around the third week after a missed menstrual period. hCG levels should double every 48 hours in a normal pregnancy and transvaginal ultrasound should be able detect a gestational sac in the uterus at around 1,500-2,000 mIU/mL. One can reliably rule out an ectopic pregnancy after detecting a fetal pole (the earliest evidence of a developing embryo) with a heartbeat. (Simultaneous intrauterine and ectopic pregnancies occur spontaneously in less than 1:30,000 naturally occurring pregnancies, but that incidence increases to 1:100 to 1:500 with in vitro fertilization.)

hCG levels that rise more slowly, plateau or decline usually indicate an abnormal pregnancy. Combined with serial ultrasound examinations will lead to diagnosing:

  • A blighted ovum if there is an empty gestational sac with no fetal pole;
  • An inevitable miscarriage if there is a fetal pole larger than 7mm with no heartbeat
  • A miscarriage or ectopic pregnancy if there is only placental tissue in the uterus at levels where we would expect to see a gestational sac.

If physicians can’t rule out an ectopic pregnancy, they’ll scrape tissue out of the uterus (a D&C) and ask the hospital pathology department to look at the tissue while still in the operating room. If there’s only endometrial tissue and no chorionic villi, the vascular bridge between the uterus and placenta, there’s an ectopic lurking somewhere.

Imaging

Ultrasound image resolution has progressed from vague static images like this:

 to detailed, real-time images such as this fetus (the four lines in the black area is the umbilical cord).

Color flow Doppler ultrasound can show blood moving in and out of an ectopic pregnancy in the adnexa, the area next to the uterus, which is helpful if the sonographer can’t distinguish a definite mass. (This, however, is Doppler flow of a heart, the only royalty-free image I could find.)

So, when a radiologist tells me, “There’s a 2cm mass with blood flow in the right adnexa, nothing but endometrial tissue in the uterus and a lot of echogenic material in the cul-de-sac running up the para-colic gutter,” I know I can skip the laparoscopy and open her up.

Surgical treatment

However, surgical treatment has also changed. Tubal ligation was the only surgical procedure we did in the early 1980s. By the early 1990s, physicians with far more balls than me, along with surgical instrument innovations, were starting to take things out of people laparoscopically. Removing an inflamed appendix became a simple outpatient procedure. Taking out a gallbladder full of stones using a laparoscope was far easier and less traumatic than the old days which required an incision along the right rib cage from stem to stern, and digging deep while your poor intern (me) tried to retract a six-inch deep wall of fat with a “Weinberg Vagotomy Retractor,” otherwise known as Joe’s Hoe (and it is as big as the garden tool).

“Pull harder, dammit!”
“I’m pulling as hard as I can!”

Operative laparoscopic surgery had a steep learning curve in the early days and I was skeptical of the newfangled approach to ectopic pregnancy. I was suckered into assisting two youngsters with far more confidence than ability and both endeavors lasted two hours. One insisted in putting a trocar (which looks like a tent stake) through the abdomen in the vicinity of the inferior epigastric artery, despite my pleas to reconsider. She wasn’t concerned with the pulsating stream of blood and continued prospecting for the ectopic pregnancy.

I got a call one Saturday at midnight from the ER doc at a small hospital in Nebraska, 70 miles away from where I was working.

“I have a woman here with a ruptured ectopic pregnancy and I want to transfer her.”
“You don’t have anyone there who can deal with it?”
“Well, the general surgeon comes here on Wednesdays but I don’t think she’ll hold out until then. I’ve started a unit of blood and the ambulance is here.”

I was working as a locum tenens in someone else’s practice. I called the senior partner since he was rather protective of the practice’s reputation and I didn’t want to step on any toes. He wasn’t happy but met me in the Emergency Room. The woman arrived about 1:30am and, after introductions, examination and discussion, we were in the operating room at about 2:00am.

Setting up for an operative laparoscopy takes at least half an hour or more after the patient goes to sleep. The equipment includes:

  • a video camera and two monitors
  • the laparoscope light source
  • the CO2 insufflator used to blow up the abdomen like a balloon so the surgeon has room to work
  • an electrocautery unit
  • reusable instruments like the laparoscope and the insufflation needle
  • an array of expensive, disposable stuff like operating ports, instruments to cauterize vascular pedicles, a combination irrigation/suction device hooked up to room suction and a bag of saline,
  • and a uterine manipulator, which requires putting the woman in stirrups, putting on the surgical drapes, using a speculum to find and dilate the cervix before inserting it into the uterine cavity.

Laparoscopic surgery starts with putting in the insufflating needle just inside the belly button, the thinnest part of the abdominal wall, then filling the abdomen with enough CO2 so there’s room enough to work. After that, the surgeon inserts at least three or four ports in the abdomen: a 10mm for the laparoscope; a 5mm just above the pubic bone for a wand to move the innards around; and 5mm or 7.5mm ports on either side for operating instruments and grasping. (I have six abdominal scars from my robotic prostatectomy.)  Click here for a great overview of laparoscopic trocar placement.

Older ports consisted of a stainless steel trocar with a pyramidal end like a tent stake inside a stainless steel sleeve which one pushed this through small incisions, taking care not to puncture the bowel, the bladder or the aorta. Newer ports are disposable plastic with more blunt trocars to minimize the chance of damage, but they take a little longer to work through the abdominal wall.

So, after setting up, gently and deliberately excising the damaged portion of tube, sucking out blood and clot, irrigating the pelvis, inspecting to make sure everything is clean and hemostatic, taking all the instruments out and closing the incisions, we were done about 90 minutes later.

My approach to an ectopic pregnancy in the good old days was direct. I’d make a small abdominal incision, grab the tube with a Babcock clamp, remove the offending ectopic, clean out the blood and clots in the pelvis, inspect the other tube and ovary, and then close her up in 20-30 minutes.

It’s one of many reasons I’m happy to pass the baton to a younger generation.

Medical Treatment

Methotrexate, a drug initially used to treat cancer and then rheumatoid arthritis, is sometimes used to treat unruptured ectopic pregnancy. There are stringent criteria for its use – a stable and reliable patient, a mass less than 3.5cm, hCG < 5,000 mIU/ml, and no detectable cardiac activity – and the woman must be monitored closely with serial hCG levels. Success rates are reported to be around 90% when used appropriately.

The emergency room physician at a small hospital in Tennessee called me around 11:30 pm on a Sunday night. A 42-year-old woman came in complaining of vaginal bleeding for a week and severe pain in her right lower abdomen.  “She has a positive pregnancy test; her hemoglobin is 8 and her pulse is about 110.”  A normal hemoglobin level for a non-pregnant woman is 12-16 gm/dl; even in pregnancy the level should be 11 or so.

I walked into the examination room and met a slightly pale woman on a gurney; her husband stood next to her.

“Hi I’m Dr. Rivera. I assume the ER doc has told you why I’m here?”
“Yes, he told me I’m going to need surgery.”
“Well, that’s a good place to start. Tell me what’s been going on.”
“I started bleeding off and on last Monday. I didn’t think much of it, but it hasn’t stopped, and I started having pain in my side tonight, so I came here.”
“Have you felt any pain in your shoulders?”
“Yes, my right shoulder started hurting two days ago.”
She noticed the look on my face and asked, “That’s not good, is it?”
 “Not really. If you’ve had internal bleeding the blood can irritate your diaphragm and your body interprets that as shoulder pain.”
“Yes, but how can I be pregnant? I had my tubes tied thirteen years ago!”
“Well, tubal ligations have an inherent failure rate. I saw one woman who got pregnant after her tubal. I took out her tubes after delivery and found an inch gap in both tubes.”
“Really!”

So I took her to the operating room. My scrub tech was the Czechoslovakian grandmother who always made sure I was well-fed when I made rounds in the morning. I was sure I didn’t need to start with a diagnostic laparoscopy and went straight to an abdominal incision. She had 1300cc of blood and clot in her abdomen from a ruptured ectopic; I took out what was left of both Fallopian tubes. By now she should be menopausal and safe from that sort of misadventure.

For all the progress we’ve made, some want to turn back the clock. Some Right-to-Life types have conflated treating an ectopic pregnancy with abortion, saying intervention isn’t necessary. The author of that article has since apologized, but the damage has already been done and such misinformation has already spread.

Graphics © Can Stock Photo
Explosion: Jag_cz
Fertilization: stockdevil
Ectopic Sites: normaals
Ectopic: Kateryna_Kon
Fetal Sonogram: faustasyan
Doppler: faustasyan

The More Things Change

7 Replies

December 13, 1977
My few days at the abortion clinic. The doctor is an OB/GYN who has also been doing abortions for 5 years. The office is attractive and comfortable. No one has ever been turned away for financial reasons. They will do abortions up to 14 weeks; after that they will refer the woman to someone who will do it later than that.

My first day; the receptionist gets a call at 8:30am. “Yes, Ma’am, I’m glad your mother did not have an abortion and I’m glad my mother didn’t either…No, we are not influenced by Communists. We don’t want to have anything to do with Communists…No, anyone who gets an abortion wants one. We don’t force people to have them.”

Every woman is personally counselled before the procedure. The woman is informed of the alternatives (having it and keeping it or giving it up for adoption, or having the abortion). The woman is asked why she wants it and is asked to sign a consent form. The procedure is explained in detail: the lab work (blood pressure, HCT (hematocrit); Rh typing and urinalysis); the actual abortion and the post session.

The woman is told what may happen as far as cramping: what to watch for; who to call if she has any questions. (Don’t go to the local Catholic hospital emergency room; women who have get pretty bad treatment.)

The first woman I go through with is young (about 20), unmarried, with her father. She is cool, a little afraid but very realistic. Everything goes OK with no problems. We talk before and after. She wants an apartment and is ready to leave home. Her father is surprisingly calm and is glad it isn’t “like the butcher shop years ago, f’ Chrissake!” We talk about Rhogam (she is Rh-negative), other methods of birth control, and so on.

The women are of all ages: young, middle aged, married with kids, single, divorced. Rich, middle class and poor. The reasons: “I’m not ready to start a family.” “I have kids and I’m getting too old.” “I can’t take being pregnant again.”  How they got pregnant also varies: rhythm that didn’t work; a busted rubber; foam and no rubber; forgot the diaphragm; just got careless.

Some want to have kids later and feel it is the wrong time to start families. Some are from small towns, some from the big city. Catholic, Protestant, other.

Many of them are resentful of the Illinois legislature. Some think the representatives (mostly men) ought to try being pregnant. Most feel the option ought to be available. Everyone is glad to get it over with and swear they will never take chances again.

One woman today expressed frustration and anger at her husband, and at men in general who think birth control is always the woman’s responsibility. I’ve heard the reasons she says her husband gives and can’t believe people are still really like that. I feel for her because she is in a rotten position and needs some support. I listen and agree with a lot of what she says; she apologizes unnecessarily for “offending me.”

Next week I’m supposed to do the counseling myself (with an experienced counselor watching). This afternoon I will spend all night in labor and delivery. Strange world.

I wrote that almost forty-five years ago during my third year of medical school and a month shy of Roe v. Wade’s fifth anniversary. This year’s may be Roe’s last.

The physician, Dr. Richard Ragsdale, was a kind and compassionate man whose face resembled Lee Marvin. He would gently explain to the patient what would happen and always gave her the option of backing out. He would close his eyes when doing a bimanual pelvic exam, as if he was trying to mentally visualize the uterus. When the procedure was over, he would help her sit up, remind her of what to expect that was normal or concerning, and ask if she had any questions.

Then, as now, providing abortions wasn’t easy. Dr. Ragsdale’s clinic was firebombed. He was forced to do pregnancy terminations in a local hospital after the Illinois legislature adopted licensing regulations for outpatient clinics that were impossible to meet. Dr. Ragsdale sued the State in 1985 (Ragsdale v. Turnock, 625 F. Supp. 1212 (1985)). The Seventh District U.S. Court of Appeals ruled the Illinois regulations unconstitutional and the case continued to the Supreme Court but was settled in 1989. Dr. Ragsdale died in 2004.

I believe a few inconvenient and irrefutable facts:

First, and most important, women aren’t capable of inseminating themselves. The single requirement for an unwanted pregnancy is a willing dick with viable sperm. No politician has introduced legislation regulating accidental fatherhood, but maybe they should.

Second, preventing unwanted pregnancies can minimize the need for abortions but that requires, among other things, affordable and easily available contraception. GoodRx.com provides cheap oral contraceptives and Depo-Provera online. An IUD can run $500-$1300 but can last up to 12 years. The Colorado Family Planning Initiative provided long acting reversible contraception to low income women, cutting teen birth and abortion rates in half. Condoms cost about a buck each, less if bought in a box of 12 or more, but they won’t work if they are stuck in a wallet.

Notice I said minimize, not eliminate. Any given pregnancy has a 10%-20% chance of ending in a miscarriage, also called a “spontaneous abortion.” Oklahoma wants to criminalize abortion “from the moment of conception,” which presumably would make inserting an IUD a felony. The State has also convicted a Native America woman of manslaughter for miscarrying her 4-month pregnancy. Texas’ draconian antiabortion law would potentially consider surgical or medical treatment of miscarriages a crime, equivalent to a voluntary abortion.  So much for “small government.”

Sometimes a pregnancy implants somewhere outside the uterus and this “ectopic” pregnancy is life-threatening. The choice is removing the errant pregnancy or letting the woman die when the tube ruptures. When I was a resident we found a live fetus the size of a rice grain in a gestational sac hanging out the end of the Fallopian tube and no, we could not just move it to the uterus. Conservative thinking would potentially consider this an abortion.

Every birth control method, even permanent sterilization, has an inherent failure rate. Several years ago I saw a 42-year-old woman in a rural hospital’s Emergency Department complaining of a week of bleeding and abdominal pain. She’d had her tubes tied thirteen years previously but never thought she might be pregnant, but she had a positive pregnancy test. I found 1,300cc of blood in her abdomen from a ruptured ectopic pregnancy.

Preventing unwanted pregnancies also requires adequate sex education and the political will to ensure it happens. Countries with comprehensive sex education have far lower teen pregnancy rates than the United States. Determined teenagers will engage in sexual activity, regardless of adult pearl-clutching and sanctimonious bullshit, so get over it.

Third, women with money will always be able to get a safe abortion, regardless of state restrictions or their personal religious affiliations and convictions. So will the pregnant mistresses of pro-life politicians who have a sliding scale of morality.

Finally, I don’t want someone telling me what to do, so no one should be telling any woman what to do!

“Since we all came from a woman, got our name from a woman, and our game from a woman. I wonder why we take from women, why we rape our women, do we hate our women? I think it’s time we killed for our women, be real to our women, try to heal our women, ‘cus if we don’t we’ll have a race of babies that will hate the ladies, who make the babies. And since a man can’t make one he has no right to tell a women when and where to create one.”
? Tupac Shakur

Like a Rolling (Gall)Stone – Conclusion

8 Replies

Thursday

It started out as a repeat of Wednesday. A lab tech drew blood around 5am which turned out to be yet another set of troponin ($254.00) and lipase ($197.00) levels and a third comprehensive metabolic panel ($202.00) and CBC ($92.00) plus $37 just for the honor of sticking a needle into my veins.

Meghan arrived at 6am to give me my daily Protonix® for reflux; Katrina would bring me the rest of the medications after shift change. This time I balked at the Lovenox.

“Do I really need that? I’ve been out of bed several times and I move around when I’m in bed, so I’m not really going to throw a clot.”
“Ok, well, you don’t have to take it if you don’t want it. I’ll let the doctor know.”
“While you’re at it, how about asking him to get rid of the telemetry monitor since we know I didn’t have a heart attack and this thing is probably costing someone a lot of money.”

Telemetry was $122.00 per hour and the total charge was $2,074.00 with another $2652.00 “room charge” tacked on.

Then the Parade of the Grey Coats started.

I don’t remember much of what the hospitalist said, aside that my lipase level was back to normal, and he would be talking with the surgeon about our conversation. Peg arrived shortly after he left.

I’m really not sure why the gastroenterologist showed up because he had nothing useful to say. Probably it’s because he could bill $366.30 for the initial consult and $192.03 for the follow up visit. He told me to make a follow-up appointment with him in four weeks, advice I promptly ignored because I’d already made an appointment with my own gastroenterologist to arrange another colonoscopy.

My cardiologist, Dr. McGuinness, recognized me immediately when he arrived. He is also my sister-in-law’s cardiologist, in the same group as her “electrician,” and he is beloved by staff and patients. He should give seminars on bedside manner and patient communication.

“It’s good to see you. I wanted to let you know your stress test was negative. I heard you might be having your gallbladder out soon.”
“Yes, I talked with Dr. DeBouw last night; he should be coming around this morning so we can finalize a plan.”
“There’s nothing more for us to do, so we’re signing off. I hope surgery goes well.”
“Thanks. It was good to see you.”

 Peg was in a good mood. However, Katrina, who must have sensed a critically low level of turmoil, arrived to top off the tank.

“Dr. Warner, the hospitalist, said he talked to Dr. DeBouw who said he would talk to you downstairs in pre-op before surgery.”

Peg and I looked at each other.

“Where did you leave it last night?”
“He was going to talk to me this morning about doing surgery now or schedule it for a couple of weeks later as an outpatient.”
“He didn’t say ‘We’re going to take you to surgery tomorrow,’ did he?”
“Nope.”
“Well, I hope he’s better in person because right now I’m not happy.”

If momma ain’t happy, ain’t nobody happy!

This could have been problematic. Insurance companies don’t like to pay inpatient rates for outpatient procedures unless done as an emergency, in which case one has to have been formally admitted. Peg had called the claims department on Wednesday and, as of 3:40pm, they had only received notification of my emergency room visit. They weren’t aware that I’d been held for observation, nor whether I’d been admitted. The person in claims said, “Some hospitals are better than others.”

Peg asked Katrina: “Who can I talk to about this? Utilization management?”
“That would be a good place to start; you can call the operator and they’ll connect you. You can also talk to the unit manager. I think she is on the floor today.”

Hospital Utilization Management (UM) departments are the bane of every physician’s existence. Utilization reviews ostensibly increase efficiency in hospital care and decreases revenue loss from unreimbursed charges by reviewing care for “medical necessity” and decreasing “length of stay.”  Physicians see UM as people paid to tell us what we’re doing wrong and why we should toss patients out “quicker and sicker.”

Peg called UM and got voicemail, which didn’t improve her mood. I called Katrina back into the room.

“Would you do a couple of things for me? First, have someone get ahold of Dr. DeBouw and let him know we want to see him here in the room, not in pre-op. I don’t know if there’s been a problem with communication, but I think it’s tacky to assume someone has agreed to surgery without a final discussion. Then can you find the unit manager because trying to talk with someone in Utilization Management was a bust.”

I sensed some annoyance, but she agreed to contact him. A few minutes later she returned and told us he was on his way to the hospital and would see us before his first surgery.  I hated to be demanding, but this is why physicians and nurses need to be on the other side of the bed. It gives the perspective one wouldn’t get without being subjected to the indignities inflicted on the great unwashed.

Dr. DeBouw arrived about 30 minutes later. He reiterated what we had talked about the prior evening, including the risks of becoming seriously ill while waiting to do surgery as an outpatient.  Peg was happy again. 

Someone from patient transportation came to fetch us around 12:30pm and took us to pre-op holding where patients are prepped for surgery. If you’re lucky, you’ll be put into a 10×12 ft. cubicle with a sliding glass door and a privacy curtain. There’s enough room for the gurney, a small wall-mounted desk and cabinet, an I.V. pump and one family member sitting in an uncomfortable plastic chair. The back wall usually has a fluorescent light bar, a wall-mounted monitor screen, and a “medical headwall system” which has outlets for oxygen, “medical air” suction and electricity. Often there’s a self-inflating resuscitation bag and mask hanging on the wall just in case someone codes in the room. Otherwise, you’ll likely be in a ward with several patient areas separated by curtains, which is also how most Post Anesthesia Care Units (PACU) are set up.

A lively nurse peeked around the curtain and said, “Your doctor will come and talk to you before we take you back.”
“Uh, we talked with him upstairs about thirty minutes ago.” Geez, doesn’t ANYONE communicate around here?
“Ok then, that makes it easier. What’s your name and date of birth? And what are you having done?”

If I’d thought more quickly, I might have made some smartass comment about having a Cesarean section for twins, but I was really tired and just wanted to get on with it.

The anesthesiologist followed. Anesthesiologists range from gregarious back-slappers through personable, reassuring people to grumpy assholes who speak in grunts. The stereotype of anesthesiologists are physicians who, much like emergency room physicians, prefer short-term, intense patient relationships, minus the need for engaging or conversing.

“What’s your name and date of birth? And what are you having done?” He wouldn’t be the last person to ask me that.

After identifying my name, my quest and my favorite color, I told him about my paradoxical reaction to Versed (midazolam), a benzodiazepine used for sedation for procedures, such as colonoscopies or minor surgeries that don’t require general anesthesia. I’ve been given it for two colonoscopies and my eyelid surgery; apparently, I tried climbing off the table for the first two and a nurse had to hold my head for the third. I don’t remember any of this because Versed puts one in a little black room without anything to distract, like elevator music.

“They gave me 6mg when I had my eyelid done.” (The usual dose is 2mg.)
“What??? That was wrong! If the usual dose doesn’t work, giving someone more certainly isn’t going to help.”
“Well, they ended up giving me propofol.”

He made a note in my chart and left. A few minutes later the Certified Registered Nurse Anesthetist (CNRA) came into the room. For the uninitiated, a CRNA is a registered nurse who has gone beyond a Bachelor of Science in Nursing (BSN), earning a Master of Science in Nursing (MSN) and completing two to three years of anesthesia training. They’re often supervised by anesthesiologists in large hospitals, but often practice independently in smaller, rural hospitals. They are cheaper to train than physicians and their salaries, while substantial, are much lower than anesthesiologist salaries.
I like CNRAs because I don’t have to deal with an outsized ego. With few exceptions I’ve found them to be a joy to work with.

Then the moment of truth arrived. I kissed Peg as they wheeled me out the door and down the hallway. Then down another hallway. And another. By now we should have reached the next county. Finally, they pushed the gurney into the room, and I climbed onto the operating table. The anesthesiologist put a mask over my face and told me to breathe deeply.

I heard, “How are you doing?”
“I’m still here.”
Not for long, sweetheart.

I’m thoroughly fascinated by general anesthesia. You’re out like a light and before you know it, you’re in the PACU babbling like an idiot. My prostate surgery took three and a half hours, but it felt like ten minutes to me. This was no different. When I woke up in recovery, I asked myself am I dreaming? I’ve had fairly vivid dreams that are almost indistinguishable from real life until I finally wake up. I asked “am I dreaming” out loud but there was still no answer. Slowly things started to come into focus, and I suspected I wasn’t in the OR.

I saw a recovery room nurse next to the gurney, making notes in the laptop sitting on the bedside table. I put my hand on her shoulder to make sure she was real. She took my hand away and looked at me.

“You’re in recovery. Do you need anything?”
“How about a beer?”
“No, there’s no beer”
“I want a beer.”
“Nope, no beer.” Well, THAT sucks!

I became aware of a rhythmic beeping sound above my head and to the left, the pitch of which began to slowly decline.

“Take a deep breath.” 

I did and the pitch rose. I nodded off and the pitch dropped.

“You have to breathe. Take a deep breath”

The beeping sound was coming from the pulse oximeter, a device which measures the percentage of blood oxygenation saturation (also known as O2 sats) through a small sensor clipped to one’s index finger. Anything above 98% in a healthy person is normal. I’ve had lifelong asthma and chronic inflammation, so my sats run around 95% on a good day.

I looked over my shoulder; my O2 sat was 89% and going down.  I took a few deep breaths and it rose to 98%. Every time I heard the pitch going down, I looked at the oximeter and adjusted my breathing because I don’t like being yelled at even though I know I’m just fine. I’m not breathing deeply because I just had three tent stakes thrust through my abdominal wall and I was breathing anesthetic gas, which I could still taste an hour later.

“Would you like some ice chips?”
“Yes, please.”

She dumped a spoonful of ice chips into my mouth which I savored, waiting for them to melt instead of chewing.

“Can I have more ice?”

Another spoonful of cool, wet ice chips. I could hear several people at the desk discussing Portillo’s, a well-known Italian beef joint in the area. That sounds good. Portillo’s and a beer.

Dr. DeBouw talked with Peg after he’d finished. My gallbladder was “ugly” and there were more stones marching down the cystic duct, so taking it out was prudent. He said surgery was “textbook” and took about 20 minutes. If recovery went well, I could go home later in the afternoon and have anything I wanted for dinner, even steak.

That sounded good, but someone hadn’t bothered to tell PACU or the floor to which I was going to be transferred. Normally, one goes from PACU to another outpatient area where the staff assesses one’s fitness to go home. “What we’ve got here is failure to communicate.”

Patient transportation took me to the fourth floor and dumped me off in a room the size of a storage closet. There was barely enough room on either side of the bed for one person. Someone had dutifully filled out the white board facing the bed with pertinent information like my nurse and her in-house phone number, my physician and what tasks had been scheduled for the next 24 hours. My new young nurse, Ashley, and her equally young assistant bounced into the room, bright-eyed and bushy-tailed, even though their shifts would end in a couple of hours.  Ashley immediately hung a fresh I.V. bag (another one hundred fourteen bucks a bag and another $753/hour for the pump).

“Let’s get you settled in…”
“Uh, I’m not planning on staying here for very long. Dr. DeBouw said I could go home this afternoon.”
“Uh… Well, let me check on that. I thought you were going home tomorrow morning.”
“Not if I can help it. I’ve been here long enough.”

She left the room, presumably to call my surgeon and confirm that I was indeed getting out of Dodge and returned in a few minutes.

“Yes, you can go home but before that you have to eat something, urinate and walk without difficulty.”
“Ok, well I peed while you were gone. If you want me to walk, let’s go now!”
“How about I have you order something from the menu, and we can walk while you’re waiting for it.” (Being able to order something charitably called “room service” is a recent development in hospital management. It’s still hospital food and sucks more often than not.)

Surgeons often inject long-acting anesthetic into the tissue around the trocar sites; I wouldn’t feel any pain until the following morning. I got out of the bed with little effort, grabbed the I.V. pole and led my nurse and her assistant out the door. I went down the hall and circled the nursing station at a brisk walk, the two of them marveling behind me as if Christ had just healed the cripple

“Well, just look at you go!”

You’re young and you think I’m ancient, but your perspective of age will change in about forty years. People in their sixties are no longer hanging out on Death’s doorstep. Neither are many people in their eighties.

My “dinner” arrived shortly after we returned to the room: desiccated grilled chicken and that tasteless broth I’d experienced the day before. The only saving grace was a small carton of Luigi’s Lemon Italian Ice. Very tasty.

Ashley bounced into the room again.

“We’re trying to contact the hospitalist because he has to approve your discharge?”
“Why? The surgeon already discharged me. Why would the hospitalist care if I’m gone?”
“Well, we just have to do it, but it shouldn’t be long. He’s already left the hospital but we’ll page him.”

After waiting another 45 minutes for the hospitalist’s blessing and satisfied that I met the criteria that would keep them from being sued for discharging me too early, they gave me the requisite discharge and follow-up information. Patient transportation wheeled me to the main entrance, stopping at the canopied walkway leading to the parking lot pickup point. He must have been tired after a long day.

“Can you make it from here or do you want me to wheel you out?”
“Nope, I’ll take it from here.”

I got into the car and Peg drove off. We stopped by Walgreens and picked up my prescription for hydrocodone tablets (I used only one), then Portillo’s for a beef sandwich before going home to my own bed. But no beer.

Here’s the damage:

DescriptionCharges
Hospital$47,914.92
ER Physician $1,264.00
Medical Group Physicians $1,850.01
Outside GI Consultant $558.33
Surgeon $2,900.00
Surgical Assistant $1,450.00
Anesthesiologist $2,475.00
CRNA $2,475.00
Radiologist $488.00
Pathologist $73.00
TOTAL$61,448.26
Medical charges May 4-6, 2021

I have good insurance which paid for most of this. We still had to pay more than $2400 out of pocket, but Peg is fortunate enough to have a Health Savings Account (HSA), which is funded with pre-tax dollars. I reached my deductible before the anesthesia group submitted its bill for both the anesthesiologist and the CRNA, $2475 each. So much for CNRAs being cheaper.

I can afford this but millions more can’t. It’s unconscionable that the richest country in the world won’t provide universal health insurance coverage. I don’t see that happening until Millennials and women run government.

(If you are interested in seeing how a gallbladder is removed laparoscopically, check out this video: Laparoscopic Cholecystectomy for Symptomatic Cholelithiasis – Extended L. Michael Brunt, MD, Section of Minimally Invasive Surgery, Washington University, St. Louis, MO.)

Sad Gallbaldder Plushie from The Awkward Store, courtesy of my wise-ass daughter. Now why didn’t I think of this 20 years ago?