Monday, March 10, 2008

Bills, Bills, Bills

I just got a bill from the second of the two hospitals for my $250 copay for admission to the hospital for a delivery. I've already paid this copay to the first hospital. After 20 minutes on hold with my insurance company, it was confirmed: I have to pay the copay twice since I spent time in two different hospitals.

On the other hand, I love seeing bills where the "billed charges" are $92,610 and "due from pateint" is $250. Hooray for health insurance!

Thursday, March 06, 2008

Wow, It's A Good Thing We Were So Worried About My Cervix (Part 2)

Up until now we've been following me. What, you might ask, was happening to H during all of this?

He had a fairly boring morning. Up at dawn (he's NOT a morning person), off to the hospital without any coffee, and then sitting around waiting to get into the room. We get into the room, and more sitting around. Sit, sit, sit. Off to lunch. Back from lunch to discover the epidural is in and Dr. Favorite is about to rupture the membranes. Cool- now things will get moving!

Um, dear? You're feeling funky? What's that? Wait, who are all these people? We're going to the OR? Um, okay, I'll follow you... I guess she needs a C-section. Well, that happens a lot, I guess that's okay... I'll just stand here... Doh-dee-doh...

I think the part where he gets taken into the OR and handed the baby to hold up for me to see goes in here. I was conscious, so he wasn't too worried and didn't ask WHY I'd been rushed off. He assumed it was the normal reason people get rushed off for C-sections-- a compressed cord or something. He was then sent off to the NICU with the baby.

Experienced Polish Nurse followed him from the OR and said something along the lines of, "I hope you realize how lucky you are." This was where he was informed of just what had happened, but he was left with the impression that all was now fine with me and headed off to the NICU where he spent some time getting the baby settled in. I'm not sure why they sent the baby to the NICU instead of the nursery. I was told later that the NICU was nearly empty and so they put him in the step down unit where he had three nurses to himself for the next few days, but again I'm not really sure.

Back to me. I know it was about 2:30 PM when they delivered the baby. I know I didn't get to the SICU until about 6 PM. What happened in between is a bit of a mystery. I was conscious, they tell me, but I have no memories from that time. I don't remember ever being told I was going to the SICU, nor do I remember being wheeled over there (it was in the hospital next door, but they're part of the same network and are connected by a corridor). I don't remember meeting my nurse, though I met her again later and she reminded me we'd met that first night. I don't remember meeting my pulmonologist, though we actually became buddies over the next 2 weeks. Anyway, at some point late that evening (maybe 8:30?) my memory switches back on and I remember talking to H.

H, by this point, was no longer in blissful ignorance. Upon arriving in the SICU, he also met my pulmonologist (let's call him Dr. LikesMacsToo) who informed him that I was "in for a rough night" but that I "had a good chance." H went white and was pulled into a conference room by Dr. Favorite, who was there as well. She explained everything to him more gently and told him that the scariest part was behind us, but that there were certainly a number of challenges to be faced in the coming days.

Anyway, my memory picks up here with H coming in and sitting with me for a bit before going home to update my mother (she had arrived the day before to stay with us and take care of D) and get some sleep. I did the following in some order that I do not precisely recall: I wondered where I was and why I was there. I asked my nurse to order me a breast pump and bring in a lactation consultant. I noticed for the first time that there were blood products going into me. I wondered what the thick line disappearing under the blanket was (the aforementioned central line into my groin). I noted I still had the urinary catheter in. Dr. Favorite and Dr. LikesMacsToo explained to me what happened. Dr. Favorite told Dr. LikesMacsToo and my nurse that she was going to sleep in the on call room tonight in case anything changed with me. I dozed. Time passed.

I was in the SICU for, I think, three days. At the beginning there was discussion of me being transferred out of there and back to my original hospital so H and the baby could room in with me, plus I'd have easier access to the lactation consultants, and indeed to a staff more familiar with pregnancy and babies (the ICU hospital doesn't see much of that). This talk died down over the next couple of days as more and more lines and drugs were removed and discontinued, but the pee-bag hooked up to my catheter remained stubbornly close to empty. They brought in an ultrasound machine and a technician to take a peek at my kidneys and bladder to see if there was any noticeable damage from the surgery, but there was nothing. The kidneys just weren't working. I had fluid going in but none coming out. This fluid started to accumulate in various tissues of my body, most spectacularly in my lower legs, and more dangerously, in my lungs (did you know they can do chest x-rays on you without you ever needing to leave your bed?). The hospital next door sent over a lactation consultant once my nurse returned the leg pump (yes, a pump for one's leg- I have no idea why) which came after she ordered me a breast pump, and demanded that thay find me an actual breast pump. Everyone warned me not to expect too much in the breast milk department but I think denial was still running pretty rampant for me.

While all this was progressing I had a healthy stream of visitors from my original hospital. Various people seemed to be making it a top priority to see me well and healthy. Experienced American Nurse and Experienced Polish Nurse came by and helped me stagger around the ICU in my first expedition on my feet. Another one of my OBs, who would deliver her daughter in less than a week, came by near tears and said she was just so glad I was alive. Several nurses that I am friends with from my stay in the hospital in the summer of 2005 for preterm labor came by. I also met Doogie Nephrologist, M.D., who was brought in to deal with the kidney issue. Dr. Favorite later confided in me that she's had him checked out and heard he was the best.

Blood work showed my clotting factors were still less than ideal and my creatinine level was rising to soaring new heights. (Creatinine is a by-product of protein metabolism, and here is used as an indicator of how well my kidneys were cleaning waste products out of my blood.) So, my kidneys were really not doing anything for me and my body was filling with fluid. The diagnosis: acute tubular necrosis (meaning all the cells in my kidneys that usually function to clean my blood had died from lack of oxygen). The solution after a few days of watch-and-wait: dialysis. We would hook me up to a machine that could (1) remove waste products from my blood and (2) remove some of the excess fluid building up in my body (another thing my kidneys were slacking on).

A couple of problems first, however. I still had the epidural in. When the pain relief I'd gotten for the delivery wore off (it takes about 24 hours), Dr. O'Wonderful kindly gave me a repeat dose through the epidural. When that wore off, I graduated to an interesting cocktail of various derivatives of morphine. Dr. O'Wonderful told me she'd take the catheter out once my platelets got above 100. Three days and two transfused units of platelets later, they still weren't even close. Also, the dialysis required a procedure to insert a catheter through my chest and into the large vein that returns blood back to your heart, which is something you don't necessarily want to go and do on a patient who is at risk for bleeding, nor do you want to pull a catheter out of said patient's spinal cord, for bleeding there could potentially lead to paralysis from the waist down.

So, they scheduled insertion of the catheter for Friday, and Thursday evening Dr. O'Wonderful sauntered in and said she was going to remove the epidural catheter, despite my straggling platelet level. There was a risk of bleeding and paralysis (in the event of bleeding they would first try an emergency surgery to prevent the bleeding from causing paralysis), but she'd consulted with the other eight anesthesiologists in the hospital, and they all agreed with her that the risk of infection from leaving it in was greater. She made it clear that this was entirely a judgment call; there were no statistics or previous cases to go by. Fabulous. Here we go then. She counseled me on exactly what order my feet, toes and legs would go numb if we had a problem, and out came the catheter. She then nonchalantly strolled to a computer just outside my door and hung out for an hour.

It was a long hour. I wiggled my toes and stared off into space.

Fortunately, the puncture site clotted just fine, as did the site where they inserted the catheter the next day (I think it was the next day; my sense of timing is pretty fuzzy here). The catheter insertion marked my third experiece with an operating table in pursuit of building my family, and while they didn't give me a general anasthetic, whatever they gave me instead caused the whole procedure to take about four seconds by my mental clock. I don't remember much from that day. I was still in a tremendous amount of pain, and couldn't do anything much beyond rolling a little ways onto my side. I pumped and pumped and got a couple of drops of colostrum. I was transferred out of the SICU to a telemetry wing upstairs to continue my recovery and get to know the nephrologists and dialysis nurses a whole lot better.

The baby was discharged that day, too, and went home with my husband. I'd seen him twice-- they brought him over from next door in an incubator on wheels with his own nurse. It hurt to hold him, and I was pretty unsteady, but I did get to hold him for a little while. H took the first photos.

Next up: fun with dialysis! Also, a related topic: how to lose 56 pounds in eight days. And a bonus for faithful readers: how it feels to take a partial shower after ten days without (one of which involved giving birth)!

Monday, March 03, 2008

Wow, It's A Good Thing We Were So Worried About My Cervix (Part 1)

The alarm woke us up at 5:15 AM for the induction. We needed to arrive at the hospital (about 45 minutes away), by 6:30 AM. Now, I knew this was patently untrue, as I am intimately familiar with the hospital's shift change schedule after my 3 months there when I was pregnant with D, but I figured we ought not to start off our technically medically unnecessary induction at 39 weeks by being late. And, as I expected, we got there at 6:30, blew through the admission paperwork in about a minute since I had actually mailed in everything I was supposed to in advance, and then had to sit there in the lobby for 29 more minutes until the nurses even started the shift change up in labor and delivery that I knew must precede our assignment to a nurse and admission to the floor. To make a long story somewhat shorter, it took us forever to even get into the room.

Eventually we got there. I undressed and put on my oh-so-familiar hospital gown, open at the back this time, unlike my first admission for preterm labor with D, where I demonstrated my about-to-be-obliterated unfamiliarity with hospitals by putting it on opening forward (the nurse wasn't quite successful at hiding her urge to burst into peals of hysterical laughter, but that's a whole different story...). We met Experienced American Nurse, who introduced herself and explained that she'd just found out that another nurse, a close colleague of hers in L&D, had unexpectedly died that morning, and promptly burst into tears. We commiserated with her for a while, and then when there was no sign of my OB, Dr. Favorite, Experienced American Nurse went ahead and started a peripheral IV and got the pitocin going so that we could get things moving.

Dr. Favorite arrived shortly, said hello, and checked my cervix. Still at 3 cm and not terribly effaced, just like one week ago in the office. So, she left us there to let the pitocin do its thing for a bit and went off to do a couple of c-sections. In the meantime, Experienced American Nurse came back and said she was going home, as she was still a bit emotional and they were overstaffed that day. We had mentioned earlier how pleased we were to have a nurse with so many years of L&D experience, as we'd heard from one of my perinatal unit nurse friends upstairs that L&D was currently staffed with quite a large proportion of new nursing school graduates, and what with my history, yadda yadda yadda... Experienced American Nurse promised to get someone equally experienced to replace her, and soon we met Experienced Polish Nurse.

(WHOOP! WHOOP! WHOOP! FORESHADOWING!!!: This was the first minor happening of the day to probably save my life...)

Meanwhile, not much was going on with the contractions. I was having plenty, but they weren't particularly strong just yet. They slowly ramped up, though when Dr. Favorite came back I still wasn't terribly dilated, but she said things were moving along okay. She had one more c-section to do, and then she'd come back and rupture the membranes to help things along. When I had D, nothing really got moving until she ruptured the membranes, so I figured this would be the same. Dr. Favorite wanted to wait until I was in a good labor pattern before doing it this time. This was cool with us. We were watching the food network on TV. This was perhaps not the best choice for a woman who had been advised to limit things to a light breakfast.

The contractions progressed. I fired off a few text messages saying things were going slowly. It was around noon. H considerately went off to eat his lunch elsewhere so I wouldn't have to watch hungrily. I was just starting to feel like the contractions might eventually become a little painful sometime relatively soon when Experienced Polish Nurse, who had already inquired if I planned to have an epidural, suggested we get the anesthesiologist in to get that going. I wasn't anywhere near my personal level of pain tolerance, and I knew that once we got the epidural in I'd be confined to bed, so I tried to put her off, but she went off to "check [the anesthesiologist’s] schedule." She returned and said the anesthesiologist, Dr. O'Wonderful, would be going into the OR soon, so I either needed to get it now or I might be waiting a long time. I went with now.

(WHOOP! WHOOP! WHOOP! FORESHADOWING!!!: This was the second minor happening of the day to probably save my life...)

I really liked Dr. O'Wonderful, as you might guess from her nickname. We had a nice chat about my background in HIV research while I was getting my PhD, and just hit it off. Dr. O'Wonderful got the epidural going beautifully and went off to the OR and I lay back to enjoy the drugs. Dr. Favorite returned, pronounced my cervix at 5 cm and my contractions showing a solid labor pattern, and ruptured the membranes. H came back and we all chatted for a while. A little more than 30 minutes after rupturing the membranes, Dr. Favorite went across the street to meet her husband for lunch.

I now know that amniotic fluid embolisms and other complications are most likely to present within 30 minutes of rupture, which is why Dr. Favorite doesn't leave patients until this window has elapsed. Anyway, Dr. Favorite was across the street meeting her husband, Dr. O'Wonderful was in the OR, and Experienced Polish Nurse wandered back in to our room. This is where things went awry.

All I remember saying is "I'm starting to feel a little funky." I was still conscious and able to speak and breathe, although I felt very slow and dopey. Experienced Polish Nurse got the oxygen mask going on me. The only other things that I remember from that room were that all of a sudden it was full of people. Very, very full. I thought to myself, oops, here we go. Must be an emergency c-section. What was actually happening was this: some of the amniotic fluid had managed to enter my circulatory system and ended up in my heart and lungs. As a result, my lungs were filling with fluid and my heart wasn't pumping as effectively as it should. My blood pressure was dropping through the floor, and many of my internal organs, and the baby, were starting to be deprived of oxygen.

From what I heard later, this is where Experienced Polish Nurse saved my life. She decided very quickly that I needed to get to the OR as quickly as possible. Others were apparently telling her it was too soon, and that it wasn't clear what was happening, and Dr. Favorite needed to be called back from across the street, but Experienced Polish Nurse took matters into her own hands and apparently pulled me in my bed, IV poles and oxygen tank trailing, out into the hall single-handedly and headed for the OR. I also heard she injured her arm or shoulder in the process.

Next, I and as many people as would fit into the OR assembled and started the fastest c-section known to man. H was just outside with the overflow of people who wouldn't fit inside but needed to be nearby in case they were needed. Dr. O'Wonderful told me later than when we all arrived, her first thought upon seeing the bustle arrive in the OR was "Oh, no, I'm just certain it's that nice biology PhD lady I was just chatting with." Of course it was, and she recognized me immediately despite that fact that by this point I was a very deep blue color due to the lack of oxygen. There is a perinatologist always immediately available in the hospital to handle situations like these, and she began the c-section. Dr. Favorite told me later than she and her husband had just started lunch when she got a call on her cell that something had gone very wrong with me and she needed to come back immediately. She told her husband she'd call him shortly (she didn't) and she took off. She arrived sometime in the middle of the c-section, and her face nose-to-nose with mine, firmly telling me to keep breathing, is the next thing I remember, aside from a lot of tugging and pain as they did the c-section. (I had the epidural going, of course, but it was designed for a vaginal delivery, and there wasn't time to turn it up to the level usually used for a c-section.)

Later Dr. O'Wonderful told me that if I hadn't had the epidural in, and she'd had to take the three minutes necessary to give me a general anesthetic, that neither I nor the baby would likely have survived.

My own few memories of what happened over the rest of that day are jumbled. I remember being incredibly relieved to see Dr. Favorite. I remember a lot of me crying "Ow! Ow! Ow!" as Dr. Favorite left a lot of Dr. Favorite hand-shaped bruises over my lower abdomen as she firmly pressed against my uterus to try and stop it from filling with blood. I remember seeing H holding a baby floating into my field of view, and someone saying "here he is" and me asking anxiously, "Is he okay?" I don't remember the answer. I remember realizing that I wasn't necessarily going to survive whatever was happening, and not wanting to leave H to raise 2 kids on his own. I remember waking up in the surgical ICU of the major hospital next door to the hospital where I delivered. I remember asking for a breast pump and sending H home to sleep for the night. That's about it, really.

I now know a lot more of what went on that day. Many of the people involved visited me several times over the next few weeks and filled me in on what happened. Experienced Polish Nurse manhandled me to the OR, where someone figured out what was happening. Amniotic fluid embolisms are rare. My hospital hadn't had one in three years (unfortunately, that last patient had died). Most OB/Gyns go their whole career without having a patient experience one. I am extremely lucky that because of my disastrous pregnancy with D, I chose to continue seeing the same group of physicians, and to deliver at the same hospital, despite the fact that several others are much closer to the house we bought and moved into after D was born. With the traffic around here, this was no major inconvenience. Again, this probably saved my life. Someone, I think it was the perinatologist who did the c-section, came up with the correct diagnosis immediately and recognized what was happening to my body.

So, last you heard, my lungs were filling with fluid and my heart wasn't pumping as effectively as it should. My blood pressure was dropping through the floor, and many of my internal organs, and the baby, were starting to be deprived of oxygen. This oxygen deprivation continued to get worse. I turned blue, and my body went into shock and protected my brain and heart by sending what blood it could to them and only them. This had the effect of depriving some other somewhat important things of oxygen, namely (1) the baby, and (2) my kidneys. Also going on was something called disseminated intravascular coagulopathy (DIC). A direct effect of the entrance of one of the components of the amniotic fluid into my circulation was that my body's clotting system was activated. Blood clotting is mainly achieved through the combination of circulating blood cells called platelets and circulating dissolved blood proteins. These factors, when activated, clump together and hopefully plug up wherever your circulatory system has sprung a leak. The amniotic fluid caused my entire body to blow its entire stock of clotting factors at once, leaving me with none to deal with the fact that (1) I had just had a baby and the place where the placenta had been attached was now a giant open wound, (2) said baby had been delivered by c-section and thus there were now several freely bleeding incisions in my lower abdomen and uterus, and (3) I now had several more peripheral IVs and a central line into a vein in my groin added to the punctures already made for my original IV and the epidural, all of which were sites that had the potential to bleed.

This was not good.

Fortunately, DIC is a known complication of amniotic fluid embolisms, plus my blood pressure was already extremely low, so they were prepared for what I needed, which were massive amounts of fluids to bring up my blood pressure, plus extensive transfusions of blood, namely packed red blood cells and units of plasma-derived blood products that include the dissolved clotting factors that my body had just used up. I think I got about a dozen units of various blood products over the next couple of days, including 2 units of platelets that will enter the story later. Add in the none-so-gentle uterine palpitation that Dr. Favorite was providing while shouting at me to keep breathing, and they managed to control the bleeding, and save not only my life but also my uterus.

At some point during the above chaos, my son was born. I found out the next day, by looking at the handwritten note on a bracelet I found on my wrist, that he was born at 2:26 in the afternoon. "1/14/08 @ 1426, Boy" it says in someone's handwriting. There's also some stuff printed on it by a machine: a bar code, then my last name, a comma, and the word "baby" and my first name. His initial APGAR was three. He needed some oxygen, which they gave him and he recovered spectacularly from a traumatic last few minutes, and rose to a 5 minute APGAR of nine. They tell me he's fine. I don't know how they know this for sure, how we can be certain that there was no brain damage due to the lack of oxygen, but I choose to believe that these people know what they're talking about. Apparently the fact that I never lost consciousness and went into cardiac arrest and needed to be resuscitated is a good sign.

Next up: Wow, It's A Good Thing We Were So Worried About My Cervix (Part 2, or The Aftermath), containing such charming exclamations as "Wow! You're not making any urine!" and "Hopefully this won't leave you paralyzed!" and "We're just going to insert this catheter into your vena cava!" Also, what was H doing while all this was happening?