INSURANCE RUNS

If you have lost your life
Without noticing it
Somewhere in your
forties
Or misplaced it perhaps in childhood,
That casualty does not
appear on the schedule. . .

From “A Schedule of Benefits,” by John N. Morris

This poem appeared in POETRY magazine in 1981 and caught my eye from the pages of The POETRY Anthology, I’m not really sure why…probably just the mood I’m in. Honestly, I didn’t mean to put the evil eye on Posada when he sat out a few games due to back spasms… looks like he avulsed his hamstring muscle his first game back. Guess that puts me ahead in the race to get back to work.

SIGNS AND SYMPTOMS

Saw Dr. Abu-Rustum at my first post-op visit yesterday. I made the appointment at their satellite facility in Commack. It had a similar setup as the Manhattan Outpatient Center, large, comfortable waiting areas, with wings of exam rooms and treatment areas. I understand they do surgical consultations and follow up appointments, as well as chemotherapy and radiation treatments at that facility. Sitting in their spacious waiting area, I grew once again very grateful for the relatively early stage during which my cancer was found as well as the rather straightforward nature of its treatment.

Dr. A smiled when he saw me, and apologized for the delay. It was over an hour since my scheduled appointment time before I got in to see him. His face grew more and more concerned as I told him of the fever of last week, the symptoms I had, many of which, chills, sweats, pelvic pressure, were now gone. He nodded at the bloody drainage that I am still experiencing, and mentioned that the pulling sensation at my wound when I urinate was very common, described most often by women having hysterectomies in the face of endometriosis where the ovaries are preserved. In a panic I asked, “Is this going to happen every month?” He assured me no, that once the post operative inflammatory response of the endometriosis calms down, when everything heals, I should not be having these symptoms again.

I confessed to him that I had tried to go back to work last weekend, but that my associate was uncomfortable with such a short recovery period. He laughed and said, “Good, I like that guy…I like his thinking…smart guy.” He was not as entertained one bit by my experience with his own office, and found it particularly vexing that he had not gotten the message that I had called with concerns. It was evident that he was not keeping up with my blog! He grew anxious to examine me.

I will spare you the details of the examination. Suffice it to say that he remains concerned about the fever, the drainage, and the healing of the vaginal cuff (the upper part of the vagina which was sewn closed after amputating the uterus). He believes that there was a collection of blood, lymph, and fluid building up inside (fevers, sweats, pressure), that has now “broken through” to decompress via the vagina (bloody drainage). He now has me on two antibiotics, three times a day, and an antifungal chaser to take on day 10 to guard against any yeast infection.

He limited my activity to walking and going up and down stairs, but no lifting, no situps, no swimming or riding a bike, stay off my feet when possible. Absolutely no sex, no douching, no tampons, nothing per vagina…really, it is very fragile, it will rupture, he warned. (Yeah, as if…!)

No, I can’t go back to work just yet, he said, because I know what you’ll do…and I don’t want you standing hunched over an OR table for 3-4 hours, or spending a morning doing 3 or 4 or 5 or 7 colonoscopies, not yet, you’re still healing. Finish these antibiotics and if everything gets better, you can go back to work. He scribbled a sentence on his prescription pad… “Dr. B—may return to full work on June 5, 2006.” Is that OK with you? I didn’t answer.

He tried to cheer me up. “Well, it’s OK with me, in fact longer than that would be OK with me, but any less than that…not OK. And if your fever comes back, I need to know.” I smiled a smile reserved for such occasions. “I’m not kidding, “ he scolded. “Please don’t go through the regular channels to try to reach me. You call the page operator at Memorial and tell them ‘This is Dr. B—and I need to speak with Dr. Abu-Rustum.’” I kept smiling, maybe even a little nervous laugh. “Seriously, M, you are my colleague. You are a surgeon. And if you think something is wrong, I need to know.”

I stopped smiling. Now I was getting upset. He sensed this. “Listen, M, you’re going to be all right. You're not septic, OK? Just a localized infection, draining, which is good. This will get better. You just have to be patient, give it some time. You are still healing. I can still see the (absorbable) stitches we used. You have to let things heal.”

I thanked him, waited for his nurse to fill out my disability forms, then went to my office to break the news to my office manager.

HOME AND AWAY

The Yankees had an amazing 5-4 win today in 11 innings against the Mets. Mariano Rivera got his first save in a while, coming in to strike out the side in the bottom of the 11th. This follows a heartbreaking loss to the Mets, where just last night, Rivera came in with the game tied and gave up the winning run in the bottom of the ninth. Which just goes to show you, anything can happen.

The Yankees have been hampered with injury this spring, just this week getting bad news about Carl Pavano, Shaun Chacon, and Tanyon Sturtze, all pitchers in what’s turning out to be a fairly meager pen. This added to a hand injury to right fielder Gary Sheffield, and a broken wrist on left fielder Hidecki Matsui. Just before yesterday’s game, manager Joe Torre added backup outfielder Bubba Crosby to the disabled list for a hamstring strain.

Former Ace pitcher Randy Johnson continued to struggle through his fifth straight horrible start last night. I was intrigued for a moment, before the start of the bottom of the second inning, after Johnson had warmed up, that catcher Jorge Posada stood from his catcher’s crouch, walked into the dugout and took himself out of the game. Recently, Posada had gotten some clutch hits, including a walk-off homer in the bottom of the ninth to win against the Texas Rangers 14-13. It is well known that throughout his career, Randy Johnson has preferred pitching to one catcher over another, and that Posada was never one of his favorites. Did Johnson ask for the change? Is he in any position to ask for such a favor? Did Posada tuck his ego under so early in the game to help a struggling Johnson or was Johnson just not listening to him, not hitting his targets, shaking off his signs, and Jorge just got fed up? Did Posada hit the bench for himself, or for the team?

These were the questions I asked myself, having grown up during the Yankees “Bronx Zoo” era, when egos loomed large, and personalities clashed in concert with on the field struggles and triumphs. No doubt the vignette held additional interest to me, considering my own experience at work yesterday morning.

I hit the office early, dressed to the nines, ready for action, ready to attend to any work that had piled up on my desk, then make some rounds. Two full weeks out from my surgery, I thought taking call this weekend, with a pretty low census (if any) in the hospital, and no major cases slated for Friday, our usual operating day, may be a nice way to ease into things, feel like I’m doing something, without spending hours on my feet in the OR.

The boss thought differently. When I called him to get the list of patients he would want me to see in the hospital this weekend, lets just say he “shook off the sign.” He said, not in so many words, “Look, M, I’ve been talking to some people, and I just don’t feel comfortable with you coming back this soon. Two weeks is too early. I’ve talked to GYN’s who do this operation and women who have had this operation and some people are out 8-9 weeks. I understand you aren’t even driving yet… I just don’t think I can take the chance of having you come back too soon…you’re a surgeon, you know what can happen, you can get an infection, herniate, bleed. I’m just not comfortable. It’s too soon. Take another week. See your doctor, get a note from him that says when it’s OK for you to come back, then maybe I’ll be more comfortable. Right now, I just would feel horrible if anything should happen to you.”

I don’t know if it was being shocked, embarrassed, or stupid, that I had no response, defense, or retort to his argument. I wanted to say I’ve been busting my ass to get well so quickly, to have as little effect on my productivity, our practice, and our patients as possible. I wanted him to know that one of the reasons I had my surgery in the city with Dr. A, was because he believed he could get me back to work in less than half the time predicted by my original GYN. I wanted to cry didn’t he realize I’ve used up all my vacation time and can’t afford to take any more time off. I wanted to sing, “Oh, put me in coach. I’m ready to play—today!”

But I didn’t. I just acquiesced, saying of course I didn’t want to do anything that would make him uncomfortable or put him in a difficult position. I packed up my things, called my husband to pick me up, and went home. I called my doctor’s office to see if I could get a note that would clear me for work on Monday, but they balked and advised me to wait until my post-op visit next week to discuss it with Dr. A. I changed out of my suit and into sweatpants. I surfed the internet to bone up on short term disability benefits in New York State. I slid into a deep, deep funk. After Posada left the game, I went upstairs to listen to the rest of the game in bed, and slammed the off button on my clock-radio when Rivera gave up the losing run in the ninth.

The official story is that Posada is out with back spasms, and I’m starting to believe it, because he sat out today’s game, too. With both teams hurting, it will be interesting to see which of us will get to come back to work first.

RAW EDGES

First, the acknowledgements: K—thanks for the wine. B—thanks for the journal. C—thanks for the New Yorker clip. S&M (ooh!)—thanks for the plant. Harper-Collins—thank you for the Milosz. T—thanks for sharing your boo-boos, making mine feel smaller and easier to heal. A—thanks for calling to check. Sis—thanks for your watchful waiting. Bros—thanks for keeping J sane. Mom—thanks for being there. Dad—thanks for letting me be a surgeon. J—thanks for letting me be a poet, and loving me anyway. G&C—thanks for letting me be the best mother I can be, even when I’m horrible to you.

Everyone, thank you for the flowers and cards, for the posts to my blog, for reading my blogs at all, for your thoughts and prayers, for helping A in the OR, for offering to help in any and all ways. All of you have been instrumental in my continued recovery.

L—the nurse from Dr. Abu-Rustum’s office called last night, bless her heart. She seemed a little more concerned this time about my malaise, although by last night I was, indeed, feeling much better. She asked about my temp. I told her I took it, only because G was trying to fake out of school sick and I had the thermometer out to check his temp, and mine was actually normal – 98.6F on the nose. Additionally, the wound had dried up, no further drainage, and the wound edges, although still red, are just kind of pouting, granulating, perhaps not perfectly apposed, perhaps hypertrophying and forming a keloid, as L suggests. Regardless of this cosmetic issue, the depths of the wound feel fine. A little “Healing ridge” around it, not too tender, except when I sneeze, no further pain with urination, in fact, not much pain at all. OK a little wave of excruciation just before a BM in the morning, which have been showing up just fine each morning since I stopped taking Percocet!

There’s another raw edge, no doubt, that I don’t have access to as yet, and won’t for another month (J’s counting, I think). The top of the vaginal “cuff” that gets sewn or stapled shut as they amputate the uterus, may bleed, from what Dr. Abu-Rustum said. He said it may get worse as I become more active, and may even resemble a period, but then should go away as the weeks go by. So far, a little spotting, but nothing unusual.

But speaking of periods, there’s one more raw edge, all that rough, friable endometriosis that’s splattered throughout my pelvis and on my ovaries. I do believe that this tissue is trying to go through the same cyclical changes in a way that my uterus used to, responding to hormones still being produced by my ovaries. So the promises that after a hysterectomy at least I wouldn’t have to worry about having my period are largely false. Since my ovaries have been preserved, good for another 10-15 years and 100,000 miles of hormones, I’ll most likely still get many of the worst parts of my period – mood swings, PMS, water-retention, bloating, abdominal, pelvic and back pains, everything but the bleeding.

So yes, I’m feeling much better, these last couple of days, but forgive me when I get back to work next week, if I seem a little “edgy.”

LOW GRADE

Patient: Doctor, it hurts when I do this.
Doctor: (in his best Grouch Marx voice) So, don't do that!

Two hours after phoning my surgeon’s office his nurse called back. She wanted to know why I was taking my temperature. I said because I feel like crap and my wound is red. I tried to go over the four W’s, but she wouldn’t hear of it. “What’s your temperature now, right now,” she commanded. I stuck the thermometer in my mouth, but held the receiver up so she would hear it beep. “You’re taking it orally?” “Mmmhmmph,” I attested. When the beep came, my temp was only 99F. I felt humiliated and alarmist. She asked me how much water I’ve been drinking, and said it seemed sufficient. Then she told me to stop taking my temperature. That it wasn’t so important to monitor it, but to take it only if I felt “feverish.” That with my ovaries out (which I corrected her that they aren’t) that I was going to feel different and that a slight temperature elevation in the morning was normal. She said to keep an eye on the wound and if the redness spreads or my temp goes above 100 again (both sceanarios unlikely, since I can hardly see the incision and she told me not to take my temperature) to call her again tomorrow. I said I would and thanked her for her time, growled for my husband to make me some lunch, ate half of it, drank some water, opened the mail, read a book with my daughter, home with an injury to her foot, took a nap, took a shower and wrote. And no, I didn’t take my temperature.

FEVER II

Last night, the right pole of my wound started to pus out. Wound edges red, discharging a scant amount of purulent drainage. I cleansed and dressed it with sterile gauze, and this morning, no real change. My temp is steadily 100.3 - 100.5F, still low grade, but went to bed with chills and sweated all last night, really the last couple of nights. Worst part...today it hurts to sit. Really, pressure in my rectum when I sit on my butt. So I'm either constipated and impacted, or I have a pelvic abscess, or both.

Luckily, I'm a proctologist. Who thought I would ever get to say that!? Saturday night, I visited the office. Probably a bad move, overall, because I tried to tend to a bunch of stuff on my desk and got myself totally aggravated. That accomplished, I raided our sample closet, and went home with a treasure trove of fiber, laxatives and suppositories that should keep me pretty clear. Saturday, using a glycerin suppository, I was able to deliver a few solid nuggets. Then yesterday I drank some lactulose and cleaned out my colon COMPLETELY. Honestly, I was seeing some residue of stuff I don't even remember eating. Which is why I don't think I'm impacted right now.

Pelvic abscess? Going to have to defer to my surgeon for that...made a call out to him this morning, but line is busy. Will keep trying, and let you know.

FEVER

Wind. Water. Wound. Walking. And I forget, is there a fifth? Four elements of concern when a patient is spiking a postop fever. Mine isn’t high 99.9F, but the fact that I’ve been trying to take more Ibuprofen and Acetomenophen (Advil and Tylenol) rather than Percocet, may be masking it, since both are strong antipyretics, and fight fever at the same time that they fight inflammation and pain.

So lets look at these. I can almost eliminate wind and walking, as earlier causes of post op fever. Getting mobilized and walking around in the hospital and here at home have prevented the complications of atelectasis and deep vein thrombosis. I don’t have any shortness of breath, chest pains, leg swelling, palpable cords of clotted veins, or calf pain.

Water. A urinary tract infection? Been drinking lots of water and fluids to stay hydrated. Urination has been uncomfortable, but more around my incision and in my pelvis, rather than burning about my urethra when I pee. I can almost imagine the bladder adhering to my healing wound and pulling on it each time it empties. But the urine itself is clear, no blood, no cloudiness, so more than likely, it’s not a UTI.

Wound. Hmm. Well the laparoscopic incisions, one inside my innie of a belly button, and two 5mm wounds on either side seem OK. The problem is I can’t really see the other, largest incision. It’s hidden under the most adorable curtain of fat and flesh and stretch marks that I ‘ve had a problem getting rid of since having my babies. When I lie down, it redistributes to almost flat, but I can’t see it lying down, and when I stand up, well I guess I have to hike it up to see the incision underneath. Still covered with steristrips, with a little old blood on them. No drainage, or fluctuance, a little firm at either pole, and some ecchymosis (bruising) between the umbilicus (belly button) and the larger incision. The length of the wound, as expected, is numb, anesthetic, but pulling my fat up to look at it smarts. So maybe it’s the wound. Guess I’ll stay in bed tonight and let the kids take care of me and keep an eye on it on the weekend.

ENDOMETRIOSIS – or How My Minimally Invasive Procedure Became Major Pelvic Surgery

I failed to mention yesterday that often when patients (and their surgeons) survive Post Op Day 5, they’re feeling much better by Post Op Day 6. As am I, watching the Yankees, hopefully, eek into first place by, hopefully, beating the Red Sox. Finally found the right amount of pain medication to allow me to spend a little more time on my feet and thus get rid of those pesky gas pains.

I don’t remember much about the hours right after my operation last Friday, but I do remember Dr. Abu-Rustum’s kind face smiling as I opened my eyes in the recovery room. “You’re going to be fine. Operation’s all done,” he said, “but we couldn’t do it through the scope – lots of endometriosis, everywhere. We made a small Pfannensteil incision, and once we got exposure, everything came out fine.” I, still being in that morphine-induced state of overall well-being, nodded my head, happy to be alive.

Endometriosis is the abnormal implantation of tissue like the lining of the uterus throughout the abdomen and pelvis, commonly involving the lining of the pelvic cavity, the outside wall of the uterus, the ligaments supporting the uterus, the fallopian tubes and the ovaries the surfaces of the bladder and the rectum. The most common symptom of endometriosis is pelvic pain, painful periods, painful sex. Some forms of female infertility are caused by endometriosis. Since the endometriosis is so much like the inside of the uterus, it responds the same way to hormones secreted by the ovaries throughout the menstrual cycle, producing blood and proliferative tissue, and because it has nowhere to go, scar tissue every month, making everything inside sticky and stuck. That’s what they found when they went in laparoscopically, and in the end, that’s what made them convert to an open procedure.

11 o’clock, or just after, looks like the Yanks are going to lose this one after all. And they fall behind the Red Sox by a game as a three-day long thunderstorm sweeps into town. They say by midnight, it will be raining cats and dogs. Oh well, you can’t always get what you want.

POD #5

A hump-day like no other. Post-operative day 5 is always the one that surgeons fear. And when the surgeon is the patient, that fear is doubled. After the assault of any major surgery, the body undergoes endocrine, immune-mediated (inflammatory), cell-mediated, metabolic, and nutritional responses to injury that culminate on or around Day 3, and reach homeostatic balance by Day 5. Day 5 is the day that many surgery-related complications will present. Wound infections, dehiscience, evicerations, small bowel obstructions, anastomotic leaks, stump blowouts…the first hints often show on POD#5.

Probably why I feel so horrible today. Every time that I laugh, cough, urinate, especially urinate, I feel like they’re doing the operation again, with me wide awake. Like my pretty healing bikini-line Pfannensteil incision is being torn open again and some ungodly retractor like a Balfour or O’Connor/O’Sullivan is being used to hold the edges wide open and apart. Ouch. And we won’t even discuss the gas pains… in shockwaves, from my pelvis to my eyes it hurts. No relief. Am I doing too much, or not enough? What should I eat? High Fiber, to make the BM’s softer, or Low Fiber to not produce so much gas? Take more pain medicine and walk around more, or stop taking pain medicine because of its constipating effects? Dunno.

Maybe I should just be happy. Cancer’s out, and you can’t die from gas pains. It’s Post Op Day 5 and I don’t have any of the major complications listed above. The Yankees have another chance to beat the Red Sox tonight. My vote for Taylor went through. I watched “Love Actually,” last night and remembered how cute Hugh Grant and Liam Neeson are. Yeah, I should just be happy.

JIGGETY--JIG

Perhaps no “Jiggety—jig,” but definitely “Home again, home again.” And it is good to be home again, although my stay at Memorial was uneventful, and everything is going fine, this homecoming was better than I’ve ever known, and a comfort like none other. Oh, I’ve come home before. Home, from college, tired, from work, even refreshed from vacation. But this homecoming was different. More knowledge than any one year of college, more tired than from any job, including my current one, and well, still on a vacation of sorts, certainly fast using up my vacation time and working hard to be more rebuilt, rejuvenated, and refreshed than on any other vacation I’ve ever taken. I know that I will never take for granted tucking my kids in at night, or the comfort of sleeping in my own bed. And tonight – the Yankees vs. the Red Sox. Jiggety—jig.

BOWEL PREP

I will spare you the gory details. Suffice it to say Fleet Phospho-Soda is not like any soda I've ever had, and my favorite clear liquid is... Luigi's Real Italian Ice!

It is so nice to hear from everybody again. Thank you for writing, for posting, for sending, for calling, for praying. I can't think of anybody to single out named Denise, but I wanted to post this poem I read today (while eating Italian Ices) and dedicate it to you, my friend. It's been much too long.

Letter to Denise
by Hayden Carruth

Remember when you put on that wig
From the grab bag and then looked at yourself
In the mirror and laughed, and we laughed together?
It was a transformation, glamorous flowing tresses.
Who knows if you might not have liked to wear
That wig permanently, but of course you
Wouldn’t. Remember when you told me how
You meditated, looking at a stone until
You knew the soul of the stone? Inwardly I
Scoffed, being the backwoods pragmatic Yankee
That I was, yet I knew what you meant. I
Called it love. No magic was needed. And we
Loved each other too, not in the way of
Romance but in the way of two poets loving
A stone, and the world that the stone signified.
Remember when we had that argument over
Pee and piss in your poem about the bear?
“Bears don’t pee, they piss,” I said. But you were
Adamant. “My bears pee.” And that was that.
Then you moved away, across the continent,
And sometimes for a year I didn’t see you.
We phoned and wrote, we kept in touch. And then
You moved again, much farther away, I don’t
Know where. No word from you now at all.
ButI am faithful, my dear Denise. And I still
Love the stone, and, yes, I know its soul.

Thank you, friend, for being so faithful, and for putting up with my meditations. And yes, we'll be "in touch" again soon.

A ROUGH WEEKEND

It was a difficult weekend for my family. I could see it in their faces, hear it in their tone. This is the week, six years ago, that my mother died. As we spent Sunday together, I could feel each person, my Dad, my brothers, my sister, even my husband going through his own personal history of her last days with us. The phone calls, the drive for us from Erie, the hospitals. In one, in Brooklyn, my Dad had practiced as a general surgeon his entire career. After my residency, I even worked there, first assisting on bigger cases, and fulfilled a dream my Mom always had for me – operating with my father. It was the last place my children, then just two and three years old, would see my mother alive.

The hospital where she was transferred next was a big Heart Hospital on the North Shore of Long Island. Here they were equipped to do everything, which is of course what we wanted them to do, since none of us were ready to say goodbye. My Dad and I, well trained that surgery can save, let them cath her, let them crack her chest, let them try for hours to patch the shredded fibers of her heart. Then she died. Nothing will ever be as painful.

My youngest brother, 36, had a pacemaker placed yesterday. The cardiologist came out of the procedure and told him in a heavy Indian accent, “Both your nodes are dead! Boat of dem!” I think he knew this, my brother. He’s had vague complaints since my Mom passed. Trouble sleeping, chronic fatigue, pains in his shoulder, palpitations. He was visiting her grave a year and four months later and took a day off from work to rest, still tired all the time. The next morning, running late for work, his subway stopped working a distance away from his office. When he got to the surface, he was carried by a wave of people coursing North. He turned to see his office building crumble to the ground.

Nothing will ever be as painful. I’m sure I thought this when Dr. Abu-Rustum gave me a date for my surgery, and I’m sure my brother thought about this when he scheduled his electro-physiologic studies/pacemaker placement. It’s a rough week for my family, anyway. And May 5th is the day my mother died. In the Catholic Church, saints’ feast days are celebrated on the day they died. I always believe that things happen for a reason. I remember explaining to my children how my mother died. I told them that her heart broke a little each time her children moved away. And that she died so she could be with all of us at once, no matter where we were.