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

Danni and Sarah

7 Replies

(I first wrote this 25 years ago. Perspective changes with time.)

I worked for a staff model HMO for nine years. Despite being a small cog in a sizeable organization, our Ob/Gyn department was like a second family to most of us. We knew about most of each other’s spouses (or ex-husbands). We shared our young kids’ accomplishments, antics and disappointments. We celebrated birthdays, expressed our condolences at the passing of elderly parents, and grieved together when a beloved young mother-to-be died in car crash. We had monthly department meetings at local restaurants after office hours, instead of trying to cram an agenda into a lunch hour.

Danni was the RN OB Intake Coordinator for our group. She was a gregarious soul with a kind heart and a good sense of humor.  She spent an hour with each new mother-to-be at their first OB visit, talking about what to expect during pregnancy, what to do (eat healthy, wear a seatbelt and keep your appointments) what not to do (smoke, drink, anything blatantly stupid or dangerous). She was usually smiling, even when one of her appointments sorely tried her patience.

If she was having a particularly stressful day I would go to her office and wrap my arms around her. She said I gave great hugs; this was back when it wouldn’t trigger a visit from HR. I remember her colorful cable-knit sweaters under her lab coat and the warmth of her cheek against mine as she hugged me back, providing a brief respite from the day’s aggravations. Sort of like Mom telling you not to worry, that everything would be alright.

Danni suffered unrelenting physical pain from a tragic injury more than a decade earlier. We all knew about it, but to hear her talk it was more of an aggravation, something she’d learned to live with. Or maybe it was to deflect from the emotional torment she carried and of which only a few were aware.

I left the HMO in 1994; Corporate dissolved the staff model a few years later because “you cost us too much money.” Everyone found other jobs in town; Danni got a position with a local clinic. Our family had been torn asunder; we drifted apart and some connections withered from neglect.

I wandered for a couple of years, working in two different practices and a couple of locum tenens jobs before being hired to set up a practice in a small Southwestern town. I’d wanted to leave the long, gloomy Midwestern winters I’d endured for three decades and was trying to get out from under crushing but self-inflicted debt. (It hadn’t occurred to me that I was abandoning my kids as well, something I would later regret.)

In February, five months into the new practice, I flew Danni and Elizabeth, another former staff member, out to help train my nurse and receptionist. My new staff had no experience with an obstetrical practice, and I was used to someone else handling patient education. In retrospect, my support staff may not have been receptive to the intrusion but I needed the expertise.

Danni promised to send me forms and other information when she returned home. I called her several weeks later since I hadn’t received anything. She seemed distracted and vague but assured me she would “get around to it when I have time.” I should have suspected something was wrong. That was the last time I heard her voice.
One evening she sent her daughter to spend the night with the neighbor next door.
And ended her pain forever.

*           *           *

Linda, a nurse practitioner I worked with, called me early the next morning, sobbing.
“Danni is dead!”
“What happened?”
“I don’t know.  She had her daughter Katie stay at her friend’s house last night. She found Dani when she came home to get ready for school.  I don’t know why, but they found a note.” 

She continued to cry.
“I remember she was suicidal when she left the clinic.  I remember telling you she could never do that to Katy and you told me ‘Don’t bet on it.’  I don’t understand.”
“I do,” I replied.  “I understand all too well.”

I talked with Peg later that day and told her what had happened.
“How are you handling all this?”
“As well as I can.”
“You know, I had a dream about you last week and I was afraid to tell you about it.  You and I were talking and you told me you were going to kill yourself in the same tone you are using now.   When I reminded you that you’d promised to keep going, you looked at me and said, ‘I was telling you what you wanted to hear.’  I heard the resignation in your voice.  How could you do that??  Don’t you realize how much it would hurt everyone, including your kids???”
“Yeah, but I wouldn’t be around to know it.”

Over the next 2 days we talked about suicide; Peg was very angry.
“It’s so selfish!  I don’t understand how she could calmly take her own life and leave her child with no one. There is always something else you can do.”

But for someone who has fallen into the abyss, such platitudes ring hollow.  I know because I lived on the edge for almost 30 years and peered into the darkness many times.  There comes a point when there is no more hope; when one has reached one’s limit of coping and can go no further.  A point at which getting out of bed in the morning takes all the energy one has.  There is nothing tangible to keep one moving, to make one want to take one more breath.  Danni had reached her limit after years of constant physical pain and believing she had to go it alone.  For all the people who cared and loved her, she finally could not continue.

The love of other people isn’t enough for some of us, because we don’t feel it is genuine or that we deserve it.  On some level, I had long viewed that conditional “love” in the context of Billie Holiday’s song, God Bless the Child:

“Rich relations may give you
A crust of bread and such
You can help yourself
But don’t take too much.”

Ironically, Nietzsche said, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.”  I survived many of those dark nights and ultimately determined I didn’t want to jump into the void.

A couple of days later I got an e-mail from Liz.
“I got your message, thank you.
I feel numb.  I can’t believe it.  I will never understand. 
Please, David, never do this!!!!!!”

*           *           *

Sarah was a 17-year old-gangbanger and troubled youth. Her father had also been a gang member, but he had turned his life around and tried to steer kids away from drugs, alcohol and living on the edge. Age and a stark reminder of mortality is often enough to trigger such an epiphany in adults, but teenagers either think they are immortal, or doomed to a life that can never change, so why bother.

Sarah was drunk the night she and some friends were playing chicken on the Interstate highway that ran north of town. They would lie on the white line while traffic approached at Autobahn speed, then run to the shoulder at the last moment.  When Sarah’s turn came, she got up too late and was struck by a car.  The local newspaper called it “an unfortunate accident” but some who knew her said she’d been severely depressed.

I went to the visitation with a family who had a troubled, angry 15-year-old daughter. I learned that when she threatened to run away from home, Sarah had talked her out it.  “You don’t know how good you have it.  You don’t ever want to live on the street!”  Her friends and acquaintances, also “gangbangers,” appeared for the visitation, crying and holding on to each other for support.

I cried the tears I hadn’t been able to shed for Danni, and for those kids who felt they only had each other.   I cried wondering why it took death to arouse family and friends from their oblivious slumber. Twenty-five years later I know some aren’t receptive to being helped, no matter how sincere the efforts.

St. Mary’s Church was filled for the funeral.  The gang members had printed T-shirts with “Turtle” (her nickname) over the left breast, and a memorial on the back: “In loving memory of Sarah Jo, 1980-1997.”   During the eulogy Sarah’s cousin told the mourners, “If you love someone, tell them now.  You never know when it will be too late.”

The procession to the cemetery stretched for 2 miles.  After the priest finished, her friends released green and white balloons and sang for her.   I couldn’t hear what they were singing. Instead, I heard a radio in the background playing “Forever Young” and then “That’s What Friends Are For.”

Melissa, 8 years old, wrote her own goodbye:

I held my 13 year old son and told him I loved him, even though I chewed his butt incessantly and tried to make him walk the straight and narrow.  He blew it off, but deep inside I knew he understood and would always know that I loved him.  I’d like to think my dad would have done the same.

A parent’s worst nightmare is having to bury a child long before his or her time. 

A child’s worst nightmare is wondering what you did to make your parent commit suicide.

National Suicide Prevention Lifeline: 800-273-8255

Turtle © Can Stock Photo / shalamov

Coaxial Exasperation Continued

4 Replies

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.

Graphics: © Can Stock Photo: sailorr (snail); tang90246 (Wi-Fi symbol).

Coaxial Exasperation

5 Replies

Three things in life are absolute certainties:

  • Death
  • Taxes
  • Cable/internet companies providing shitty service

Cable used to be far simpler.

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

Image Credits:

© Can Stock Photo
artmyth (Rabbit Ears)
trekandshoot (VHF dial)
PixelRobot (UHF/VHF dials)
Gordo25 (Coax connection)
Amindesign_89 (penis silhouette)