Que est-ce que c'est Amphibole?

My husband says that my blog is too serious, so I'll try to lighten things up for this post. I won't guarantee you will laugh, however....

You may be wondering what Amphibole is.

Amphibole is a mineral of metamorphic (or igneous) origin. I like the concept of external forces shaping us, but that we retain our core character through those experiences.

A related word is amphibology, a logical fallacy, or an ambiguous grammatical construction. Life is seemingly logical but often not...

Here is an example of an amphibology from Groucho Marx:

“ I once shot an elephant in my pajamas. How he got in my pajamas I'll never know. ”
- from Animal Crackers

And a couple of cute and short ones:

Eat our curry, you won't get better!

No food is better than our food!

And a literary example from statemaster.com: From or section does not cite its references or sources. ... Edward II, an Elizabethan play written by Christopher Marlowe:

Edwardum occidere nolite timere bonum est.

Depending on how the reader punctuates this line, this can be interpreted as Edward's death sentence, or as an order to preserve Edward's life

Fear not to kill the king, 'tis good he die... kill not the king, 'tis good to fear the worst. (5.4.8-11)

Sources: http://www.statemaster.com/encyclopedia/Amphibology and Wikipedia

Lucky

I am optimistic, but not usually lucky. Luck struck twice this week.

Jessica's friend was able to get me onto the surgery schedule as an add-on. This meant that my procedure would be done at the end of the day. I was told to arrive at the hospital at 1 pm, and that my procedure would likely be at 6 pm, but could be as early as 3 pm. I was issued a cute operating gown with flaps to pump in hot air. It provided much better coverage than the typical hospital gowns that never manage to cover your bum. A nurse came to give me an IV. I told her that I have really small veins, but she did tried to insert an IV in the top of my hand anyway. We ended up with an IV in my forearm, and yet another needle in my other arm for a blood draw. I had not eaten since 6 am, since doctors do not want you to not eat for 8 hours before receiving general anesthesia. I was smarting from the needle pokes, and getting increasingly hungry. I was starting to feel sorry I had not kept the morning procedure in Richmond, where I would not have had to have an IV.

Finally a little after 6 pm, my turn came, and they wheeled me into PACU, which turned out to be the real pre-op/post-op room. I heard moaning and heated voices from the other beds. I forced myself to keep reading the Economist. The Economist as my happy place. Oh dear.

Jessica's friend came by to reassure me a couple times before my procedure. Then I met my surgical team. All women! A nice girl power moment as I was wheeled in to the operating room.

I didn't remember anything more until I woke up again in PACU. The haze wore off after an hour or so, thought I don't clearly remember whether the surgeon or my husband told me that I had lost a lot of blood during the procedure. They estimated a liter. I might need a blood transfusion. I would need to stay overnight at the hospital.

The hematocrit level is the percentage of red blood cells in your blood. WHO provides guidelines for normal levels for women at 36%, pregnant women is 33% (see http://www.anemia.org/patients/faq/). One of the surgeons said I started the procedure at 33% and halfway through I was at 27%. They would take another blood test overnight, and if my hematocrit was below 20, I would need a transfusion.

I realized I didn't want a transfusion. I had agreed to one before the procedure. It seemed so unlikely that I would need it, and natural to accept it to save my life. But, now that I had made it through the procedure, I didn't want it unless the situation was really, really dire. I recalled the risks the doctor had reviewed before my procedure: less than 1:2 million risk of Hep C, less than 1:2 million risk of HIV, 1:200K of Hep B (actual infection rates for for Hep C and HIV are 1:2.6 million: http://www.merck.com/mmpe/sec11/ch146/ch146e.html). There are other potential complications, including various types of rejection or reaction to the transfused blood.

To stop the bleeding, during the procedure a balloon with 30 cc of water had been put in my uterus. The balloon pushed on the blood vessels in the uterus to stop the bleeding. My geeky side was very happy with this tidy little solution.

The next morning, my blood test was back. 27. I had not lost as much blood during the surgery as originally thought, possibly closer to a half-liter. No transfusion. Slowly, the water was taken out of the balloon. 15 cc, then 2 hours waiting, the other 15 cc, and another 2 hours waiting. Then the balloon was pulled out. It turned out that it is actually a catheter for incontinence. Hmm, I liked the dual purpose but it didn't seem as cool any more.

Finally, I was released from the hospital at 1 pm, 24 hours after being admitted. I had been lucky ending up at the hospital for my procedure. If I had gone to a clinic, especially outside of Kaiser, would they have been able to deal with my bleeding complications?

When it rains, it pours. Or at least sprinkles: Lucky incident #2. I logged into facebook and found I had won a Hitachi mini hard drive with an Infectious skin (friend Tim Robert's company - infectious.com). I never win anything, so winning something I don't need is still exciting!

Trials and Tribulations of HMO's II

My sister-in-law called last night. Jessica had a friend in ob/gyn at Kaiser. Maybe this person could help. In 30 minutes I was on the procedure list for the next day in SF. I was reluctant to give up my appointment in Richmond because it had taken so much to secure it. Irrationally, I was scared that the SF appointment was not "real". After many confirming questions about the procedure, timing, etc., I took the SF appointment. I felt more comfortable in a familiar place.

This last turn of events makes me feel very lucky. In the end, I got the outcome I wanted. But, it took hours of trying and a personal connection to make it happen.

From a physical safety standpoint, I don't understand why my nurse practitioner or any of the other nurses I spoke to on the phone didn't make this option available to me. Space could be made if needed. I don't know if it comes down to systems issues, cost or desired spare utilization in case of emergencies. It really makes me question the HMO concept. Clearly quality of care needs to be balanced with cost/efficiency, but balanced not compromised. And, is this a design issue - where whoever designed this system has a different perspective on "balance" from me, or is it poor systems/IT/process design that is impacting their ability to deliver the quality of care expected. I don't know where to take this yet, but I have a friend who is a consultant at Kaiser, engaged in process re-engineering. Will start with scheduling dinner with him...

The Trials and Tribulations of HMOs

I am a Kaiser baby. I was born at the Oakland Kaiser. When we were still in the days of paper file, folks were always surprised at how low my medical ID number was, and yet how thin my file was (we moved to Houston shortly after I was born, and I only returned to Kaiser after college). From a business perspective, I liked the efficiency of Kaiser. I knew that sometimes it was harder or took longer to get something done, but I believe that Kaiser is doing a lot of things right. I also know that regardless of the health system you are in, you have to be your own advocate.

The first appointment for surgery that Kaiser San Francisco could give me was April 30 – nine days longer than I wanted to wait. I needed to move forward not only because of my physical concerns – the potential for septic shock – but also for my mental well being.

I asked Jenna at Kaiser, my ob/gyn care provider, if I could go to another Kaiser. This was Jenna who had been so wonderful on Monday. When she measured the fetus size and detected no heartbeat she effectively switched from happy and upbeat to facts, soothing, and outlining my options – all while we were suddenly in the middle of a power outage. My favorite thing she said that day was "This sucks."

Jenna's response to my request to go to another Kaiser was essentially that they had started my care at San Francisco, and should complete my care there. I asked the same question to the nurse who was to help me prepare for the April 30 appointment. She found a referral for me to Choice, an abortion clinic in San Francisco, that was covered by Kaiser insurance. She also told me that if I wanted to be seen at another Kaiser, I would need to reach out to those facilities myself. Great.

I called my friend at Planned Parenthood. Her feedback on Choice was: variable. Some of the providers are good and experienced, others not as much. Great.

I called the Kaiser hotline, and spoke with an advice nurse. I asked her to reach out to other ob/gyn facilities in the area – Daly City, Oakland, Walnut Creek, Richmond, San Mateo. The responses dribbled in over a day as the local offices called me back. Daly City and Walnut Creek could not take me any earlier. San Mateo did not do the procedure. I never heard from Oakland. Great.

I cancelled my appointment at Choice, and made an appointment at Planned Parenthood. Just to give myself options. I know the organization well, and trust its care. Even though it would not be covered by insurance, in this case time was more important than money.

Then Richmond Kaiser called. They would take me this week. They could take me this week! Weirdly, 30 minutes later I got a call back from San Francisco reconfirming that their facility could not take me any earlier than April 30, and they had no knowledge of my Richmond appointment.

Hours of time. And, I'm lucky that my husband helped me with the calls and research. I still want to be a believer in HMOs. All the people I spoke with were very nice and helpful and really understood why the situation was causing me emotional stress. But, they didn't have the ability to help me with my problem. I had to continue to be my tireless advocate. And this was just for one appointment, one procedure.

Strangely and perhaps serendipitously, I'm feeling victorious, not sad right now. The miscarriage feels miles away.

My Options

There are two options for terminating pregnancy – or in my case making the miscarriage happen: medical management or surgical management. There is a third option, expectant management - essentially waiting - but given that nothing has happened three weeks after fetus death, I've already exhausted that option. I liked the idea of medical management because it seemed natural and more personal. I would take mifepristone (RU486) to block progesterone in my body, and then misoprotol to induce the uterus to contract. Medical management is 90% effective up to 8 weeks, but it drops to 60-70% at nine weeks. And, there is higher risk of hemorrage. Surgery is a faster/cleaner option, but there is some risk of injury which can result in heavy bleeding or infection, and the cervical injury could impact future fertility.

I love data. Data makes me comfortable and happy. Finding data quantifying these risks has proven to be difficult. Especially since most of the available information is slanted toward abortions versus miscarriages.

In the end, I decided on surgery without the comfort of data. My Chinese Medicine doctor and a friend at Planned Parenthood were both concerned about how far along my pregnancy had been, and the fact that I might have a lot of necrotic tissue which would best be removed quickly to prevent infection.

Decision done. Next: my battle with Kaiser.

Pregnant in my head

Yesterday morning, I was a mom-to-be. This was the thirteenth week of my pregnancy. I was so excited to be at the end of the first trimester, getting ready to openly announce our coming baby, excited about the prospect of maternity clothes. I thought the only gate was our genetic screen, scheduled for this Thursday.

I didn't think anything significant of my monthly check-in which took place yesterday afternoon. At the end of my appointment, I was pleasantly surprised that I would get to hear the heartbeat during this visit. I had only heard it once at 7 weeks. My nurse practitioner could only detect moving liquid with her portable monitor, so she rolled in an ultrasound machine. Jenna started an ultrasound on my stomach, finding only a 9 week old fetus and no heartbeat. Then we lost the power in the building. It would not come back until evening. I was sent home with the knowledge that I didn't have a baby any more. I wasn't a mom-to-be anymore.

I am having a "missed miscarriage". Still feeling pregnant – breast tenderness, what I thought was round ligament pain. No bleeding or spotting. Jenna said that my body is still producing pregnancy hormones. Maybe my spirit wanted this so badly that it just kept pushing my body forward in pregnancy mode in spite of the death of the fetus. My breasts are still tingling. It's hard for me to get my head around the reality when I don't "feel" it's true.