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Unpopular

Okay, so it’s not like I was *ever* one of the cool kids.  I got left behind when people were picking teams for kickball most of the time.  My red-headed nemesis in 6th grade used to pull on my pigtails to harass me on the playground.  (Joke’s on him – we ended up dating half a dozen years later).  But popular or not, no one likes to be openly rejected.  When someone you thought was a friend stops speaking to you with no explanation in high school, it’s easily attributable to the whims of teenagerhood.  But as an adult – well, no one likes to be disliked.

So I’ll admit it, my feelings are still a little hurt by having been fired by my OB last month.  Sure, I’m worried about what to do about my care.  Sure, I’d like to move on.  But let’s face it:  mostly?  My ego is bruised.  My feelings are hurt.  I feel rejected, and I *hate* that.  No one wants to be broken up with – it’s much better to be the breaker upper than the break-ee.

But, since I am currently OB-less, because the cool kids kicked me out of their practice, I need to suck up the hurt feelings and move on, which is precisely what I’ve been trying to do.  Oh, never mind that my former OB has failed to send me my medical records yet.  It’s not like I requested them two weeks ago or anything.  Oh, wait, yes I did.  See?  Another fine reason for me not to be there anymore.  Their loss, not mine, right?  RIGHT?

So I had a consult appointment with a new OB today.  Everybody loves him.  Four separate women referred me to him, independent of one another, and the perinatologist had him on the top of his list for people for me to talk to.  I couldn’t have asked for better recommendations – everyone has high praise for him, and I was particularly pleased with the fact that he is  a sole practitioner, so I wouldn’t have to worry about getting lost in the shuffle at a big practice.

I didn’t have my medical records with me to provide him, because my former OB’s office still has not sent the records to me, so I gave him a quick sketch of my medical history and brought him up to date on what’s been going on with my current pregnancy.  He asked a lot of questions, clearly didn’t love the answers, and I don’t think he cracked a smile once – well, he smiled when he introduced himself to me, but nothing after that.

And, essentially, he’s not sure he can take me on as a patient.  “It’s a lot to take on, especially this far into your pregnancy.”  He thinks I should be on TPN, but won’t order it himself, because he hasn’t done so since he was a resident – instead he’d want me to get in with a GI doctor pronto to get them to order it and manage it from there.  That would mean juggling three doctors: the OB, my perinatologist, and a GI doctor.  (Nevermind my primary care pracitioner, and my neurologist).  He’s not opposed to a VBAC, but definitely didn’t sound thrilled about it – he said he would insist on an epidural at 4-5 centimeters, and I’d have to be in active labor (no induction) or 2-3 cm dilated by 40 weeks (I would love to GET to 40 weeks!  Right now I’m just trying to get to next week!).  He can (and does) handle a hyperemesis patient.  He can (and does) handle a patient at high risk for PTL.  He can (and does) manage a patient with underlying medical issues.  Etc.  But with me – it’s rolling all of that into one patient, and that… well, that’s a lot to take on.

Frankly, I appreciated his candor.  A lot of doctors would have said, “no problem!” instead of really thinking about the impact of taking on a patient like me.  He seemed to think I’d probably just be better off seeing only the perinatologist (I’m all for it), but he said he’d talk to Dr. P. tonight or tomorrow and he’d call me to let me know how he thinks I should proceed.  Honestly, it was both overwhelming and a bit of a relief to have a doctor look at it all down on paper and admit that it’s just a lot, and an extremely complex pregnancy.  My old OB made me feel like I was hysterical over nothing (I was never hysterical, for what it’s worth).  They made it out to be a pregnancy that was no higher risk than any other, and that I was making a bigger deal than I needed to.  At least SOMEONE is taking me seriously.

Meanwhile, I’m still OB-less.

Honestly, I’m beginning to get a little worried.  How long can I go without a primary OB to turn to?  How long can I hold off on making other decisions about my care (e.g. should I do progesterone shots to mitigate some of the risk of preterm labor?) before it’s too late?  I’m too high risk for a midwife, I can’t possibly have a home birth (not safe for me – though I totally dig the idea, and absolutely understand why other women do it).  I clearly need solid prenatal care.

I just wish I understood exactly what led to my old OB firing me, so that I could at least not do it again.  The OB I saw today has worked a lot with my old OB’s practice and he said he has NEVER heard of them sending a letter terminating care without a detailed explanation and a signature from one of the doctors taking credit/blame for the decision.  My letter was unsigned (just listed the names of the members in the practice) and did not provide sufficient explanation for the termination.  Just “we feel that you need to find a provider with whom you can have a more communicative relationship.”  So I’m left with… a whole lot of nothing.

I see the perinatologist again on the 18th.  I plan to suck it up and ask him to please just take me directly.  I don’t know how much longer I can handle uncertainty like this.

Still OB-less

I’ll write more later, but the long and the short of it is that I’m still, for the moment, OB-less.  Saw the shiny new OB today and he doesn’t know if he’s comfortable taking me on as a patient because of the complexity of care that I require.

Sigh.

Perinatology Update

So I saw the perinatologist yesterday.  I had a 3:30 appointment and I was done with the growth ultrasound by a little after 4pm.  Baby is growing perfectly – has a brain, legs, feet, hands, arms, spine, etc.  The sonographer couldn’t quite visualize the four chambers of the heart, but she said it’s a little early for that anyway.   Heartbeat was a respectable 158bpm, I think.    I didn’t get any printed pictures, but to be honest, the baby was never in a great position for a good picture anyway.  I mean, lots of good pictures of ulnas and femurs and fingers and such, but not so many that really resembled a baby and not Skelator.  I’m pretty sure I saw the “money shot” a few times, but fortunately, I’m good enough at ignoring such things that I still have no idea whether this is a boy or a girl.  I don’t want to know before delivery day.  Anyway, the important thing was that the baby is growing and so far seems to have all the anatomy in place that s/he should have at this point.  I’m pretty sure the baby was sleeping through the whole U/S – not much activity, even when the sonographer was poking my belly to try to get a reaction.

Once the U/S was done, I let the sonographer know I’d like to make sure to speak with the doctor (at the perinatologists’ office, patients don’t typically meet with the perinatologist at U/S appointments unless there’s a problem or the patient needs to ask the doctor any questions).   Dr. P. had stepped out to do an emergency cerclage removal – so I was given the option of waiting or talking to Dr. G. over the phone (he was at the other office).  I like and respect both doctors a lot, but I really wanted to see Dr. P. in person if possible, so I waited.  He got back to the office just before 5pm and then spent a solid hour talking with him (this is part of why I love him).

I told him that my other OB “fired” me and he laughed and said, “How the hell do you get *fired* by your physician??!!?”  So I explained what happened and he was pretty flabergasted.  The practice that fired me is a very well respected practice, Dr. P. works really well with them, and until recently, I loved them too.  Everybody loves them – I only know one person other than me that had any issues with that office – and that was a clashing of philosophies/personalities, not a concern about quality of medical care (this other person is… how shall I put this?  Kind of a witch).

He talked about possibly coming to a decision point about just moving me over to TPN.  I told him we’d sort of been dancing around the issue up until now and that I really just don’t know where the tipping point is – at what point do we decide enough is enough and just move to parenteral nutrition?  He said, “Unless you’re feeling better and think this is going to be gone in another couple of weeks, I think we’re there now.”  He wasn’t pushing to make the change immediately, but to definitely have it in mind as I’m trying to find a new OB (more on that later), and if I wanted to move to TPN before I get settled with a new OB, he’ll be happy to handle putting in the orders for it with the home health company.

He volunteered that he’s happy to cover me while I’m trying to get settled with a new OB.  And he gave me some recommendations for doctors to talk to.  The first one he mentioned was the doctor that I’d already set up a tentative appointment with for next Monday.  He said he’s a really good guy, excellent doctor, has the advantage (and disadvantage) of being a sole practitioner, and can afford to have some flexibility in terms of my care and management of my pregnancy.  He said that they work very well together, so it would be a good fit if I feel comfortable with him.  If that doesn’t seem like the right match, he gave me a couple other names to consider, and will cover me for however long it takes to find a new OB I’m comfortable with – even indefinitely.  But I think I’ll probably have a good fit with the doctor on Monday.  I just have some things I want to clarify with him, and ensure that he can work with my home health company and what his practices re: high risk pregnancies are.  Dr. P. thinks it will be a good fit, but didn’t push it.

I asked about the rash that I seem to get from the Phenergan.  He said he doesn’t find it entirely shocking, though agreed that it’s odd that it is limited to my left arm when the Phenergan’s going into a central line.  He agreed with my assertion that despite the negative side effects, I’m still better off with the Phenergan than without.  I asked if he’d ever used a steroid protocol for hyperemesis and he said he hasn’t, but he’s seen it used with some success.  He’s had the most success with a low-dose thorazine drip, as odd as that sounds.  He was certainly willing to discuss options and keep an open mind.  I told him I don’t want to make any drastic changes to my protocol before Monday when I see Dr. F., and he said that was fine, and that either I or Dr. F. could feel free to call him anytime to discuss changing the protocol if necessary.  Mostly, he’d just like to see me getting some actual nutrition at some point, though admitted that the *most* important thing is the fluid, which I’m getting already.

I noted that I’m starting to have contractions already and he said that so far, my cervix still looks good (it did at this point in the triplet pregnancy also), but reminded me that sometimes there can be a drastic change without a lot of warning.  The hope, of course, is that my issues with the last pregnancy were largely related to the triplet factor, but it’s clear that I probably just am going to have issues with contractions even in the singleton pregnancy, so they’ll monitor my cervix very closely and make sure that they’re careful about any shift.  Yes, tocolytics are likely in my future, but probably not necessary yet.

He’ll see me back in two weeks and two weeks after that.  If I need to see him in the interim, that’s fine.  Also, he’s the doctor on call this weekend, so if I need anything over the weekend, he’ll already know what’s going on and is happy to handle it for me.  I mentioned that my old OB practice probably *has* to deal with me right now if something happens and he agreed but said that unless it’s a clear emergency (like sudden, heavy bleeding), they could be difficult about it so absent a clear emergency, he recommends I just call him directly.

So all in all?  It was a good appointment.  I got most of my immediate concerns addressed, and I have a reasonable plan for the future.  Now if only I didn’t feel so cruddy – but that’s neither here nor there.

That Magic Number

Mostly, I don’t question what’s going on with my pregnancy – I don’t sit waiting for the next appointment with a doppler or ultrasound machine to find out if I’m still pregnant. I don’t need independent confirmation right now because I’m fairly certain that I wouldn’t still be throwing up in the event of a sudden fetal demise. So, mostly, I just don’t question my status as a pregnant woman. But you can’t totally take the infertile out of a veteran like me, so I admit that I am sometimes skeptical of the long term prospects of remaining in this state.

I don’t have any good reason for questioning it, but it seems to take a certain amount of hubris to assume that there will definitely be a baby at the end of all this sickness. I would have thought that getting into the 2nd trimester would have left me feeling better about the future. I’m well past the point of my miscarriage three years ago. I’m well into the 2nd trimester. And yet? Occasionally, something reminds me that it’s an awfully big assumption to make that all will be well. In some ways, I’m grateful for the constant, if miserable, reminders that I’m very definitely pregnant right now.

So what number will I have to hit to believe this is all going to be okay? I don’t know. I think I was about 31 weeks before I believed that with the triplets. But those are triplets. It was natural to worry.

For some reason, I can’t get out of my head that a pregnancy loss before 20 weeks is a "miscarriage" and after 20 weeks is a "stillbirth". For some unknown reason, I rarely consider the possibility of stillbirth, despite the fact that I know several women who have had stillbirths. For some unknown reason, it’s the risk of "miscarriage" specifically that crops up in the recesses of my mind occasionally.

I think there’s a societal feeling, at least around here, that miscarriages happen. That a baby lost through miscarriage never really had a chance in the first place, so that life is, somehow, less relevant. The trauma and tragedy isn’t as concrete as a stillbirth. A stillbirth is a real BABY that died in people’s minds, but a miscarriage was the loss of something… less. I know that we in the infertile blogosphere understand that this isn’t true, but in the general society? I think that the dividing line remains, at least in the collective subconscience. For whatever reason, I’m not worried that I’ll have a stillbirth – I don’t think of it as a real possibility. But there’s also something about knowing that NO ONE would deny me my right and need to grieve that loss, whereas an earlier loss… well, you’re just expected to get right over that.

I know I’m talking in circles, mostly because I’m trying to get these thoughts out of my head and onto the virtual "paper" in front of me.

However screwed up my "logic" (or lack thereof) is, I feel like when I hit 20 weeks, I’ll just… feel more secure. But, for the most part, like I said, it’s not that I sit around thinking about the fragility of this pregnancy. For the most part, I assume I’ll have a family of 7 (!!) next year. I’d just like that little voice that occasionally pops up and says, "you know it’s not too late to have a miscarriage!" to go away.

This episode of self-pity and self-indulgence is brought to you by the letters H and G and the number 5.

Itchy

Toward the end of my triplet pregnancy, I acquired cholestasis in addition to everything else that was going on.  The tell-tale factor was that I was unbelievably itchy, particularly on the palms of my hands and the soles of my feet.  It was excruciating and the only good thing about it was that it was really only the last 10 or so days before I delivered.  I really hate itching.  It leaves me feeling powerless and out of control.  Worse, there seems to be no relief from it.  The cholestasis was probably the least  alarming thing that happened during my triplet pregnancy – but it was also the thing that almost pushed me over the edge.

So imagine my amusement with this pregnancy – my arm itches like mad where the dressing on the PICC site is.  And I’ve got a ridiculous rash all up and down my left arm, which seems to be exacerbated by the Phenergan (which is odd, because the Phenergan is going in a central line, so the rash should be systemic; plus, Phenergan is an antihistamine, so it’s illogical that I would have an allergic reaction to it).  I never, ever stop itching.  UGH.

Anyway, I left you hanging on my last post, so here’s the update:  I’m not in tremendous pain anymore – I had had an abscessed tooth, which resulted in an emergency root canal last week.  Not my idea of a good time, but at least the pain is gone.  I still, obviously, have the rash on my left arm, but I decided it’s not an emergency, and the home health agency keeps a good look at it every week, so if it were really alarming, they’d alert my now-former-OB or the perinatologist.  And as for the cramping and spotting?  Well, it’s just what I *do* in pregnancy.  It comes and goes, and I can live with it.

More annoyingly, I’m already starting to feel contractions now and again, particularly when I get dehydrated.  This is definitely something I could live without, but I’m seeing the perinatologist tomorrow, so I’ll see what he has to say about it.

On a brighter note, I think I felt George moving around today for the first time.  I’m reserving judgment until it becomes more regular and/or frequent, but I think it’s the real deal.

And that?  Is really all I have energy to write about right now.

So I’m OB-less.  You know that.  But, of course, out of the goodness of their hearts* the practice “is available for emergency medical care only until 12/20/2009.”  So… what constitutes an emergency?

I mean, does the fact that I’m in excruciating pain right now and don’t know what my pain management options are constitute an emergency?  I’m guessing not, but I”m not certain.

So, if that’s not an emergency, does the horrific rash that is running up and down my whole arm and seems to get worse when I get a dose of IV Phenergan constitute an emergency?  I mean, it’s not life-threatening, so is it an emergency?    It’s getting worse, but it’s still mostly limited to a fairly local area (from my left shoulder down to my left wrist).  Is this an emergency?  I’m guessing not, but I’m not certain.

And if neither of those are emergencies, try this one on for size:  What about the cramping and bright red spotting I’m having right now?  It’s been going on throughout the pregnancy – on and off, mostly off and now it’s back. Does this constitute an emergency?  I’m guessing not, but I’m not certain.

I’d continue to speculate – but I have an unbelievably bad toothache right now, and my brain isn’t quite functioning.  Sigh.

 

————————-

*Oh, right – that would be “out of compliance with the law”

Silver Lining

So, while I know that you all were absolutely convinced that I should switch OBs – I wasn’t so sure.  The issue I had was mostly with one of the triage nurses at the practice, but I have my reasons for liking the doctors (one in particular), and medically, they were giving sound medical advice.  I didn’t want to start all over again with a new practice, knowing that I’d probably have very similar issues even with a new practice.  Besides, after I explained my frustrations to Dr. R. on Tuesday, there was a huge improvement in how things were being communicated to me.

But, it’s a moot point.  Because they’ve taken it out of my hands:

Dear Ms. Perky,

We regret to inform you that our practice will no longer be able to provide medical services to you.  We feel you need to find a physician with whom you will have a more communicative relationship.

Our practice is available for emergency medical care only until 12/20/09, which is 30 days from the date of this letter.

We suggest you place yourself in the care of another physician without delay.  You may wish to contact the State Medical Society at the number or website listed below for assistance with selecting a new physician.

[insert contact information here]

We have enclosed a medical records release form with this letter.  You may mail or fax the completed form to our office.  There will be no charge for the medical records transfer.  Your medical records will be available in our office for the period of time required by law.

Sincerely,

Drs. So and So, So and So, and So and So

 

You’d think this letter would have made my day.  After all, I wasn’t overly thrilled with them right now anyway, right?  But if they hadn’t fired me, I would have had time to wait until my perinatology appointment in less than two weeks before figuring out what to do about a new OB.  But I can’t be left without an OB for that long – I’m being followed by a home health agency, and they need a doctor to communicate to and to receive orders from.   But that hardly constitutes “emergency care” because it’s essentially maintenance care.

I don’t want to pick a new doctor without my perinatologists’ input, but if I call there, I won’t be able to talk to the doctors, I’ll be talking to the nurse who will just give me a name or two out of their files.  It is unlikely that I’ll be able to get an earlier appointment, since next week is Thanksgiving week, so I’m just going to have to wait.  But then – who do I tell the perinatologist to send my report to?  They can’t send it to my current OB because, again, that’s maintenance, not emergency care.

In an ideal world, I’d switch to a midwife – but I’m not a good candidate for a midwife.  So… I’m sort of stuck.

Finally, if I’d left on my own terms, I would have been able to come back for GYN visits after I delivered.  I no longer have that option.  I’ve had horrifically bad experiences with GYNs in the past and I had finally found a practice that I was comfortable with.

I know that the silver lining is that now I don’t have to agonize about whether to leave a practice that was rarely responsive and was completely inflexible in my care.  But it still smarts.  I hate it when people don’t like me.