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.
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.
Finally, I don’t want someone telling me what to do, so no oneshould 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
We switched to Sempiternity because Awesomely Terrific and Tremendous’ internet kept going out, but what we gained in reliability we lost in signal strength to our upstairs offices. The guy who installed our cable and network recommended the new Sempiternity Capsule, a Wi-Fi extender that is supposed to “help eliminate dead spots,” augmenting the pitch with buzzwords like “consistent,” “seamless,” “performance,” and “enhanced.” The Capsules are “optimized” to work with the Sempiternity Grand Portal, meaning you are SOL if you bought your own router to avoid the rapacious rental fee.
Amazon sells the Sempiternity Capsule for $189 each. Sempiternity sells one Capsule for $119 ($199 for two) but charges an outrageous fifteen bucks for “shipping and handling.” One might figure going to the local retail store would be quicker and easier.
And one would be wrong.
I walked in and there was barely three feet between the front door and the long desk planted like a TSA checkpoint, behind which was an employee (excuse me, “customer service representative). He instructed the man in front of me to move into the corner to my right, where another rep was dealing with a woman, then turned back to me.
“What can I help you with today?” “I want to pick up a Capsule.” “Ok, can I have your first name and first initial of your last name?” “David. R.” “Ok, David, have a seat and someone will be with your shortly.”
I spotted nine customer service desks occupied by only five representatives. (Eventually, two more reps showed up.) There was least a dozen more people trying (and failing) to maintain social distancing in the two seating areas (*cough* holding pens *cough*). The middle one had several leather chairs while the one near the back had two benches with no backs, sitting perpendicular to each other. A young man with a tablet mingled with the people lucky enough to score a chair, assuring them someone would eventually call their names.
I took a seat on an uncomfortable bench with no back, across from a Hispanic man and his son. A large TV was silently running an episode of the Chopped Star Power tournament with Dorothy Hamill and three people I didn’t recognize. I couldn’t identify where the crappy bass-heavy music was coming from. I assumed this was going to take a lot longer than I’d hope, so I started the stopwatch on my phone.
Like most media stores, this one was built more for showcasing merchandise than creature comfort and/or efficiency, and I noted a few problems:
Sound bounces around in an open setup and the ambient background noise increase exponentially with each additional body.
The customer service reps were calling out names in uniformly inefficient decibel levels.
Many of the customers were old people with bad hearing and the aforementioned crappy music didn’t help.
As I looked around, I spotted the Capsules on shelves next to the TV. I grabbed one and returned to my seat, which was now occupied by a trio at the other end. Seriously, folks, there is no need to travel in packs during a pandemic, even if we are nearing the end.
No one responded to a few of the names called; I assumed they’d become frustrated with the wait and left. By now I’d been sitting there for twenty minutes, but I didn’t want to leave and have to start all over another day.
Finally, a very nice woman and one of the later arrivals called my name. I walked over to her station and put the Capsule on her desk.
“You want to return this?” “No, I want to buy it.”
She started futzing with a tablet, even though there was a computer screen on the desk. She scanned the box’s barcode, then started muttering to herself. A few minutes later she asked a sweet young thing with two-inch fake fingernails for help. Then they both started muttering.
“I’ve been working here a long time, but they just switched to using tablets and we’re all trying to get used to them.”
Great.
After more muttering and futzing, she asked me for my credit card, swiped it through the port on the tablet and I thought we were done.
“Do you want a paper receipt, or have it emailed?”
“Email would be fine.” (I HATE paper receipts because of the clutter and the propensity for disappearing.
“What’s your email address?” “It should be linked to my account.” “Uh, we can’t get to it through our system.” For fuck’s sake!
“Give me your tablet and I’ll type it in. It will be a lot faster than spelling it for you.” Some people don’t know what a curmudgeon is and those who do think I’ve misspelled it. No, I spell it that way because “curmudgeon” was already taken, presumably by a kindred spirit.
Thirty six minutes and twenty seconds later I was in my car heading home.
One activates the Capsule with the Sempiternity phone app. (I’m not sure what someone without a smart phone is supposed to do, since Sempiternity won’t send out a tech just to set it up.) The YouTube setup video says it’s supposed to be simple:
Make sure the phone’s Bluetooth is on and searching.
Plug in the Capsule and hold the phone within six inches.
After the Capsule is recognized, wait up to five minutes for the system to bring it online.
So, went up to our second floor bedroom, plugged the Capsule in and waited.
Nothing happened.
Well, almost nothing. A tiny light in the Capsule turned blue, then green and started blinking. A circle of continuously changing hue ran around the “Connecting the First Capsule” graphic for 10 minutes before the light changed to blinking white and the app said, “Your Capsule is not online.” I tried again using an outlet in the hallway. Nothing.
I went downstairs to the kitchen and tried again. No dice. Finally, I plugged it in to an outlet in my family room about six feet from the Grand Portal.
Nope.
I shouldn’t have been surprised. Our upstairs cable box kept turning itself off every ten minutes about an hour after the installation guy left back in November, prompting a visit to the Sempiternity store. I waited a couple of days for my patience to renew.
I thought arriving ten minutes before the store opened would avoid the crowd. Silly me. There was already a half-dozen people milling around in the cold, waiting for the door to unlock. I joined them rather than find myself even further back of the line.
The customer service dude took my name. I grabbed one of the more comfortable chairs this time and restarted the stopwatch, making a silent bet with myself on how long this would take.
Someone called “David?” after about ten minutes.
I walked over to the desk, Capsule in hand and said, “I want to return this. It doesn’t work and yes, I tried several times. I don’t want a replacement.”
“Ok, well, let me take care of that for you.”
He took the box and scanned the barcode with his tablet. Frowning, he tried again. He turned the box over in his hand, possibly looking for another barcode (which didn’t exist). He called one of the other customer service dudes and they huddle for a few minutes.
“Uh, I can’t do refunds with the tablet. I have to use that computer over there,” which was tied up with another customer.
Ah, the irony. Corporate sets everyone up with tablets that should do everything but can’t process refunds.
This time only took 20 minutes, minus eight for standing in line outside.
It should be intuitively obvious but remember customer service reps are just poor bastards trying to earn a living. Most of them are nice and try to be helpful, even when dealing with abusive assholes. Taking your frustrations out on them by yelling, screaming or indignantly asking to see the manager isn’t helpful. They aren’t responsible for long waits and uncomfortable seats. It’s likely none of the corporate types who design retail outlets have ever set foot inside of one, let alone as a customer. So be polite, say “thank you,” and count your blessings if you work for a company that truly gives a shit about their employees.
Afterword: I ordered a tp-link Wi-Fi 6 Range Extender from Amazon for $70. The instructions were simple: 1. Plug in the extender in an outlet near the router. 2. Download tp-link’s Tether app and create an account. 3. Tap + in the app to connect with the router. If wi-fi LED is solid blue, you’re good. 4. Plug the extender in at the desired location. 5. Enjoy your extender.
We lived in Bisbee, Arizona from the late 1950s until the mid-1960s. The nearest television stations were 100 miles away in Tucson, far beyond the range of “rabbit ears” antennas, so rural communities like ours had Community Antenna Television (CATV). Several towers erected on Juniper Flats, a plateau on the mountain northwest of town, captured VHF (Very High Frequency) signals and distributed them to houses through coaxial cable. A small adapter allowed one to connect the cable to the two antenna terminals on the back of the TV and voilà! A great picture, no snow, no ghosts and no need to fiddle with a UHF ring tuner (that “U” on the dial). Everyone watched the same shows, and we liked it, dammit!
Rabbit ears antenna
By 1970 cable had became more popular as many households ditched their antennas. The shift happened despite early FCC meddling and intimidating ads the networks aired in movie theaters decrying the evils of “pay TV.” Yet Home Box Office successfully launched in 1972 and has been with us for fifty years.
Televisions changed over the next several years. Manufacturers added a separate UHF dial as more channels became available, eventually replacing both dials with a single internal tuner. Cable connected directly to a coaxial port. Small children served as early channel changers, performing double duty as antenna adjusters. Actual remote controls evolved from wired (Zenith’s “Lazy Bones”) through primitive wireless (Zenith’s “Space Command” and Magnavox’s “pig whistle”) to ultrasonic and finally infrared.
Videotape became popular in the 1980s but with only one port available, the cable had to be routed through the player/recorder and then to the television. One tuned to Channel 3 or Channel 4 to watch a videotape. Later televisions had two coaxial ports and early game systems supplied a box switch.
An alphabet soup of basic cable networks – CNN, TBS, TNT, CBC, TLC, VH1 and others – proliferated during the 1980s. A smarmy meme noting MTV’s 40th anniversary read, “Thanks for 12 years of great music!” Basic cable provided us with “hundreds of channels and nothing worth watching,” but the cable companies hadn’t yet evolved into the rapacious apex predators we loathe.
Then the Internet happened.
Those of us who bought the first home computers remember primitive online communication through dial-up Internet Service Providers (ISP) like Prodigy, Compuserve and, of course, America Online (AOL). Who can forget the gentle sounds of your computer modem trying to connect with the AOL servers? A 14,400 baud modem gave me the blinding transmission speed of 14.4kbps to go along with my 16mHz computer clock speed. Those were the days!
But dial-up tied up one’s landline and few people could afford to spring for a second line. It was also expensive; AOL charged an hourly fee until it switched to a flat monthly rate. My 14-year old son ran up a $400 AOL bill during August 1996. (Boy, you gonna be mowing lawns until your 20s!)
Cable companies saw an opportunity and would soon pounce.
Bombastic Cable Pirates provided our cable when we moved into our house in 1998. Our Internet was still a DSL (Digital Subscriber Line) shared with a fax line. I don’t remember how much it cost, but it seemed reasonable at the time. That is, until the price jumped after the two-year introductory rate ran out. Peg was able to talk them into continuing the lower rate a couple of times, but that didn’t last. Most cable providers enjoy near-monopoly status and are only interested in hooking new customers, not retaining their existing ones.
Or, to quote Leo Getz: “They fuck you! They fuck you! They fuck you! “
We didn’t mind the price increases until they started eliminating channels, one by one, from our tier, moving them into the higher tier which cost a lot more. Complaining fell on deaf ears, as Stan and Kyle discovered when they confronted their local cable company. So, when Awesomely Terrific and Tremendous showed up in our neighborhood, promising much better customer service AND broadband Internet, we jumped – from the frying pan into the fire.
We signed up for the company’s Triple Delight package: cable, broadband internet, and switching our landline to VOIP (Voice Over Internet Protocol). The Triple Delight with Eggroll Cellular Service would have given us an additional discount, but a few years back, Awesomely offered me $600 to leave while I was working a long-term job in Nebraska. They’d assumed I’d moved there and were not pleased having to pay service fees for another company’s network every time I used my phone, even though my billing address was still in Illinois.
We were content with them for the next several years, until the inevitable price hikes started. Again, Peg managed to bargain for a lower rate a few times, but then our Internet started dropping out, first occasionally, then daily, then multiple times a day, making it completely unreliable. The modem frequently reset itself at odd times, or we had to manually reboot the system, watching that little grey circle go round and round, sometimes for several minutes. Calling Awesomely Terrific and Tremendous to complain went nowhere. “Bob” or “Dylan” or “Steve,” tech support guys with thick South Asian accents, would “run diagnostics” or fiddle with something remotely, promising resolution which never materialized.
Eventually we contacted Bombastic, which had been renamed Sempiternity (“We’re everywhere; there’s no escape!”) in January 2021. They said, “We’ll be happy to come out but you have to clear a path in the snow so we can get to the box.” Would you also like hot cocoa and cookies? They wouldn’t be able to bury the new cable until the ground thawed, so we opted to wait until fall.
A Sempiternity technician installed the new system in early November. It took him two hours to decipher the previous wiring, but he was very pleasant and thorough. He told us we might need to get one of Sempiternity’s new Wi-Fi capsules to boost our upstairs signal.
The only glitch was the need to exchange the upstairs cable box, which inexplicably turned itself off and on every ten minutes. I exchanged it at the local Sempiternity store relatively quickly and we were in business. (I had to ensure the lawn service people didn’t run over the exposed cable during their last visit of the season, but we had a relatively warm late fall, and they buried the cable before Christmas.)
When we were sure everything was working, Peg called Awesomely Terrific and Tremendous to cancel our subscription.
“We can’t cancel it today because our network is down.” Ah, the irony.
Even more ironic was the Saturday Night Live skit, airing two days later, about one man’s ordeal trying to cancel his cable subscription.
All was going well until I bought the Wi-Fi capsule. But that’s a story for the next post
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:
Description
Charges
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.
Morning started at 6 a.m. with the Procession of Medications, a pill to prevent reflux, and my nurse noting my lipase level was down to 2,000. A tech took my temperature, blood pressure and pulse oximetry. The day shift nurse, Katrina, brought more meds around 7:30 a.m. which I took with the water I wasn’t supposed to be drinking.
“Uh, didn’t they tell you not to drink?” Nope, this is the first I’ve heard.
She also injected a dose of Lovenox®, an anticoagulant to prevent a deep vein thrombosis (DVT), because it had been ordered, not because I really needed it. I didn’t have the presence of mind to question it because I was tired but it seemed superfluous. My risk for a clot was low since I hadn’t had major surgery, I wasn’t bedridden, I don’t smoke and I’m not pregnant. Yeah, I’m old and fat but so what? (I refused it the next day, which is good because that little sucker was $119!)
An hour later a woman from Respiratory Therapy, who looked and talked like the commandant at a German women’s prison, appeared with one of the newer brand name steroid/long acting bronchodilator inhalers. Remember what I said about hospital meds costing a lot more? This one retails for about $450 and lasts 14 days; the hospital charged $570. My generic version, which lasts a month, is $40 with GoodRx®.
“I have an inhaler for you and I’m going to teach you how to use it. You pull back the cover and it’s very important that you hold it correctly with the vent side up. Then you take a deep breath and hold it.”
I pulled out my albuterol rescue inhaler. “I’m a physician. I’ve been using inhalers for a long time.”
She snapped at me. “You should NOT have your own inhaler! We are responsible for you and must know every medication you are taking! Another respiratory therapist would turn you in.”
Now she reminded me more of General Burkhalter from Hogan’s Heroes. Turn me in? What is this, Stalag 17? Are you going to send me to the Russian Front?
She watched while I inhaled like toking from a bong, then put it in a plastic bag which she placed on the shelf below the TV. “Someone will come back tomorrow for your next dose.” You think I’m so stupid that someone has to watch me?
No, it’s because the hospital can charge $424 to “administer” the medication and $323 to “demonstrate” how to use it! What the hell do people without insurance do with those kinds of charges?
The Parade of the Grey Coats began around 9 am. Doctors (usually men) in white coats often cause spikes in patients’ blood pressures, so now most wear either grey or blue lab coats to minimize the psychological trauma. Or maybe it’s because white coats are a bitch to keep clean. (I have a royal blue lab coat with a Grateful Dead patch on the pocket.)
The internal medicine hospitalist showed up first. Now, I’m not sure what a hospitalist does other than generating revenue and confusion while making it possible for office-based internists to never set foot in the hospital. I’m sure I’ll get a lot of shit for that but my sister-in-law’s experience with hospitalists, who are usually much younger than the seasoned staff physicians, was exasperating.
He asked me to recount the events that ended with my admission, the third request if you’re keeping count.
“How are you feeling?” “Better than when I came in.” “Well, your lipase levels have come down nicely to around 2,000 with the I.V. fluid flushing it out. Do you mind if I examine you?”
He poked my abdomen in a few places. “Does that hurt?” “Not much but you’re not as rough as the ER doc last night. Do you know Dr. Nell?”
He chuckled, “Yes, I like her, but she can be a little, uh, enthusiastic.” That’s a polite way of putting it.
“Your lipase levels suggest you have pancreatitis. You’re not an alcoholic and you don’t smoke so it’s likely caused by gallstones. That pain you had may have been a stone passing, especially since it didn’t last too long and you’re feeling better. I’m going to order an ultrasound of your gallbladder. We might be able to send you home later today, but we’ll have to wait for the GI guy to see you.”
We interrupt this tale for a moment of education and enlightenment.
THE PATHOPHYSIOLOGY OF BILIARY PANCREATITIS
The gall bladder is a pear-shaped organ that lies below the liver. It stores and stores bile, which digests fats. Bile leaves the gall bladder through cystic duct. The pancreas also secretes digestive enzymes through the pancreatic duct which joins the cystic duct, forming the common duct. Both empty into the duodenum through the hepatopancreatic ampulla, also known as the Ampulla of Vater (Darth Vater?), which is controlled by the Sphincter of Oddi. Sounds like something out of Norse mythology.
The gall bladder also provides a source of income for general surgeons when it becomes inflamed (cholecystitis), full of stones (cholelithiasis), or both. Stones form when, for unknown reasons, stuff in bile crystalizes and forms gallstones, in much the same way stuff in urine crystalizes to form kidney stones. If a stone gets stuck in the common duct, it blocks secretions from both the gallbladder and pancreas, resulting in gallstone pancreatitis, which is what I had. Pancreatitis can also result from excess alcohol consumption, smoking, prior abdominal surgery, obesity, infections, injuries, and pancreatic cancer.
Abdominal ultrasound is the easiest way of finding gallstones and often cholecystitis, as inflammation thickens the gallbladder wall. Other, and far more expensive, diagnostic methods include nuclear medicine scans, Magnetic Resonance Imaging (MRI), or Endoscopic Retrograde Cholangiopancreatography (ERCP), looking directly into the duct with an endoscope.
A common home test for cholecystitis is consuming a greasy meal which results in excruciating upper abdominal pain; however, this is not medically recommended.
Now, back to the program already in progress
Peg arrived around 9:30am.
Did I ever mention Peg hates hospitals? No, she REALLY hates hospitals. Her mother said, “Hospitals are where you go to die.” If Peg has the big one at home, she wants me to just hold her hand and stroke her arm until she passes. Then, and only then, can I go through her office looking for the lam money.
She also thinks there is a lot of waste and abuse, albeit mostly inadvertently because no one thinks about cost in a hospital. This is largely true. I worked for a staff-model HMO thirty-five years ago. “Managed care” was withholding care from patients for profit and employed physicians weren’t good enough to work with “real doctors.” Forty years later most physicians are employed by heartless entities, and I got the last laugh.
“So, what’s happened so far? I talked to your nurse about 5:30 this morning and she said you had a good night.”
“Yeah, my lipase level has come down to two thousand something. I saw the hospitalist earlier; he thinks I have pancreatitis from passing a gallstone. He ordered an ultrasound and said I might get to go home…depending.”
“Do you have any pain?” “No, I feel pretty good right now.”
Just then a guy from Patient Transportation appeared in the doorway. He took me down for ultrasound on my bed, reversing the previous night’s course. I stared at the ceiling again as we went left out of my room, into the elevator, down to the first floor, out and a couple of left turns before backing me into a cramped ultrasound exam room. The ultrasound tech introduced herself, squirted warm ultrasound gel on my abdomen and started the exam. About fifteen minutes later she finished.
“And….?” “You’ve got gall stones, but you didn’t hear that from me.” “My lips are sealed.”
As the transportation guy wheeled me out someone from nuclear medicine said: “We’re going to see you later.”
Once back in the room I told Peg what we’d both suspected. Then the gastroenterologist showed up – not exactly a fount of wisdom. At his request I repeated the events of the previous 12 hours for the third (or was it the fourth) time. He pushed on my abdomen, and I winced.
“Well, at least it’s in the right place. Your ultrasound showed you’ve got gallstones. We’re going to get a CT (Computed Tomography) scan to confirm the diagnosis and a general surgeon will see you later today.”
“Ok, how about not giving me another liter of fluid? I’ve had three in the past ten hours, and I’ve been peeing every two hours.” “Yeah, that’s probably a good idea. We’ll also try you on clear liquids.”
Peg and had a discussion after he left.
“You told me it didn’t hurt, and you told him it did.” “It didn’t hurt when you asked me. It hurt after he reefed on it because it’s inflamed, not because I’m lying to you.” “Getting a CT scan to confirm what we already know is a waste of money! The ultrasound showed you have gallstones; a CT scan is redundant. It’s not going to give any better information. And THIS is why healthcare is so expensive!”
Peg had a point. If you’ve already made the diagnosis with a $1,000 ultrasound scan, why tack on another $3,000 for a CT scan to tell you the same thing? If an ultrasound might be difficult because of extreme obesity, then just do a CT. (Side note: Later that day the general surgeon told me the CT scan was used because ultrasound can’t evaluate the pancreas very well for things like fluid collections or tumors, which is important when considering surgery.)
We saw the cardiologist next and recited my history for the fifth time. I recognized his name; he is the “electrician” who did my sister-in-law’s cardiac ablation. She absolutely loves him, and his partner is my cardiologist, so I trusted whatever he had to say.
“Your EKG and troponin levels were normal. You haven’t had a recent stress test and we’ll have to clear you if you’re going to have surgery.”
I had a stress test in 2017 because I’ve no reliable family history and I was going to start work as a hospitalist. Unfortunately, a normal stress test doesn’t mean you won’t drop dead a few weeks later like Tim Russert.
There are two ways to do a stress test. The time-honored tradition is to hook a patient up to a 12-lead EKG, run him or her on a treadmill until the pulse is at least 130, and see what happens. ST segment changes suggest coronary artery blockage. (So does grabbing one’s chest and having the big one.) The test runs a few hundred bucks.
The other way is a cardiolite stress test, injecting the subject with a radioactive tracer and scanning the heart before and after the treadmill. A decrease in uptake after exercise suggests blockage and may indicate which artery/arteries are affected. The tracer and scan add several thousand bucks to the procedure, even though it is of questionable benefit in someone who has no history of coronary artery disease. Coronary angiography, injecting dye through the coronary arteries, is still the definitive test for detecting blockages.
The charge for an outpatient study is considerably less than doing the same thing in a hospital:
Item
outpatient
inpatient
Treadmill
$325.00
$1,200.00
Tracer
$720.00
$918.00
Scan
$1,634.00
$5,532.00
Interpretation
$300.00
$300.00
TOTAL
$2,979.00
$7,950.00
Cardiolite Stress Test: Comparing outpatient and inpatient charges
A nuclear med technician came in with a syringe containing the isotope in a shielded container and transportation took me down in a wheelchair instead of a gurney. This time I could at least see where I was going. The cardiac evaluation unit was below the first floor and reminiscent of the Batcave.
One of the women in the scanning room explained the procedure, then had me lay on the slightly uncomfortable scanner bed. The initial images took about six minutes, then they wheeled me across the hall to the treadmill room. Another tech applied twelve more EKG leads on my chest and abdomen, on top of the six leads I had for the portable monitor. The woman running the test explained what was about to happen.
“You’ll be on an incline on the treadmill. It will start out slowly for a few minutes, and then I’ll increase the speed until your heart rate gets to 130. You’ll have to keep that pace for at least a minute. Try to go as long as you can. When you need to stop, I’ll slow the treadmill for a one-minute cool down phase. I see you have exercise-induced asthma. Do you have an inhaler?” “Yes, I do but the respiratory Nazi told me I shouldn’t have it in the hospital.” “Well, she’s wrong; we like treadmill patients to have their inhalers on hand.”
Left hand, have you met right hand?
The incline was fairly steep, more than I’ve ever tried at home. I held onto the bar across the front of the treadmill to keep from falling backwards. The pace was manageable despite feeling I was hiking up a mountain.
Then, to quote Emeril Lagasse, she “kicked it up a notch.” Actually, several notches. It didn’t take long for me to hit the target heart rate. I managed two minutes at that speed before I told her I had to stop.
“Are you having any pain or trouble breathing?” “No, I’m just way out of shape and too old for this shit.”
I went back into the scanner for about three minutes before being wheeled back upstairs. I napped for a while, while Peg sat in the corner playing with her Kindle and looking at the news feed on her phone. I figured no news was good news.
The day nurse came in a little after 1pm to tell me the CT scan was scheduled for around 4pm and I’ll get oral contrast to drink around 3pm. The guy from transportation arrived a little before 4, followed by the nurse.
“Wasn’t I supposed to drink some contrast?” “Uh, you didn’t get it?” Would I be asking you if I had?
She sputtered a bit and disappeared, possibly to give someone an ass-chewing, and to get the CT scan rescheduled. Peg rolled her eyes.
“If you were just a regular patient, you would have gone for your scan without asking any questions. They would have done the CT, discovered you didn’t have the oral contrast, and sent you back upstairs, and repeated it later. And you wonder why I hate hospitals.”
I saw the surgeon around 6:30, after Peg had gone home to feed Baxter. We hit it off immediately. He extolled the virtues of removing gallbladders with a laparoscope and I told him about assisting on an open cholecystectomy when I was an intern. Back then they made an autopsy incision from the breastbone along the right rib margin, then pried the muscles apart to get to the gallbladder. The guy I helped with was fat and needed a very large retractor called a Joe’s Hoe for exposure. Yeah, it looked like one could till soil with it.
“There are two options. The first is to have the surgery since you are already in the hospital, and you’ve gotten cardiac clearance. The other option is letting you go home and scheduling this as an outpatient. I’d recommend doing it now because we know you have gallstones and you’re likely to have another attack within three months. It’s better to take care of it now, because I’ve seen people wait and then come in with a necrotic gallbladder. They end up in ICU on I.V. antibiotics and sometimes a ventilator because they are really sick.” “My wife works long hours. I need to talk to her and make arrangements. What is the chance of passing another stone in the next two weeks?” “It’s likely pretty low but not zero. You might want to just get it over with.”
Well, that sounded good to me; I wouldn’t have a lot of time to think about going under again. We talked about my prostatectomy; he said taking out my gallbladder wouldn’t take as long, and I could probably go home a few hours later.
“I know your surgeon. We’re actually very good friends, even if he did go to Ohio State.” Oh God, he’s a Wolverine. They can be sooo insufferable! But he seems like a decent guy.
“In the meantime, you can have a clear liquid diet tonight. Don’t have anything after midnight in case you decide on surgery. I have one case in the afternoon.”
I called Peg.
“He said we can do it now or do it later. I told him you had to work and could we do it in a couple of weeks. He said we could but there was a chance of another attack before surgery.” “Well, what do you want to do?” “He’s coming back in the morning and you’ll probably be here before him, so you can ask him any questions. If I do it tomorrow, I won’t have a lot of time to think about it.” “I’ll go along with whatever you want.”
Katarina brought me two cups of contrast just before 7pm.
“Drink these now and I promise you’ll be downstairs for your CT scan around 8pm.” Well, this better happen!
Someone arrived just before 8pm and took me down to the CT room. It was cold, probably to protect the equipment which can become very warm. The tech who met me was a scruffy guy who reminded me of the dude that drove the school bus down to the water when a bunch of us went canoeing at Turkey Run State Park in Indiana during college. (His “mandatory safety instructions” were “If the brakes go out on this bus, put your head between your legs and kiss your ass goodbye!”)
“Marian will help you lay on this skinny bed while I get everything set up. I’ll let you know when I push the I.V. contrast because your head will start to feel warm and then you’ll think you’ve peed your pants. You’ll have to hold your breath a few times but that doesn’t last long. Do you have any questions?” “Nope, let’s just get this done.”
The scan was as he described. I held my breath a few times while the scanner did its thing. The I.V. contrast created a brief sensation of warmth in my head and nether regions, passing quickly. I was back upstairs by 8:30 and I called home to say goodnight to Peg and to Baxter, who wasn’t taking this very well at all. He paced Tuesday night until 2am and this promised to be another fitful night.
Maybe tomorrow would bring a reprieve from all this fun and excitement.
