Surgery

I've had a crazy 48 hours.  After enduring pain and discomfort over the long weekend, I called my doctor on Tuesday and got a mid-afternoon appointment.  My exam lead to a referral for an ultrasound at 7:30 p.m. that evening, where a large blood clot was found.  That discovery lead to being admitted into the hospital and a 1:00 a.m. CT scan.  My string of medical interventions finished off yesterday with a last-minute decision for a late-afternoon surgery. I'm exhausted, but feeling thankful my medical issues are on the path to being resolved.

When my doctor first broached the subject of surgery the next morning, I was scared and overwhelmed.  Until that point, I was being kept in the hospital for observation and even though the CT scan hadn't ruled out continued bleeding, my hemoglobin levels were steady and I was actually feeling the least amount of pain I had had in days.  I was bored out of my mind sitting around my hospital room and I missed my family, so I tried asking the doctor if I could leave and just come back every three hours for another blood draw.  Otherwise, I was just hanging out around and feeling like I there was no reason for being there. 

Before my doctor even determined surgery was necessary, she had insisted she felt more comfortable if I stayed in the hospital until she could be sure I was going to be okay, because it's easy for young and otherwise healthy people to tolerate a lot of bad stuff going.  Indeed, I'd put up with a lot of pain and discomfort over the past two weeks as proof of her point.   But since I was feeling pretty decent by yesterday, I thought maybe all I needed was to continue resting.  Despite how healthy I looked, my doctor impressed upon me how I could go downhill very quickly and she'd rather that happen in the hospital and not at home in the middle of the night. 

Despite how well taken care of I was at the hospital, never in my life did I want to be home with my family so badly than when I was faced with an unknown amount of time in a hospital for reasons I wasn't so sure required me to be there.  Thinking about my kids and wanting to be with them made me cry.

My case was apparently unusual enough that my doctor consulted her colleagues who've treated many patients with ectopic pregnancies and complications as a result and they determined that the state of my health was a "ticking time bomb."  Yes, if the internal bleeding had indeed stopped, I'd be fine and the blood clot would have been absorbed into my body. But if it didn't and the clot ruptured or broke up, the consequences would have been disastrous.  Although the decision to operate isn't taken lightly, being able to remove the blood clot would be an instant cure. 

I was nervous going into surgery, but was at least feeling somewhat reassured that because I was having laparoscopic surgery, the recovery would be a lot easier than when I had c-sections. More importantly, I reminded myself that I have to take care of myself for Oliver and Soren.   

For all the worrying I did about whether I even needed to be in the hospital at all, the discoveries during surgery showed exactly how serious of a situation I was in and how I truly was the ticking time bomb my doctor had referred to me as.  Surgery turned out not to be just the best option, but an absolutely necessary one. 

My doctor's original goal was to remove the blood cot, drain out blood that had gathered in the abdomen and then stop the bleeding.  As soon as she got in there though, she couldn't see past the fallopian tube, which was swollen and heavily scarred.  She immediately removed it so she could see past the "mess." Because the tube was in such rough shape, she assumed at first that the ectopic had implanted there.  Once the fallopian tube was out of her way, though, she discovered that the ectopic had actually implanted in one of my ovaries, which had split open completely in half and was still bleeding and covered in scars.  So not only did I have an ectopic pregnancy, but I had a very rare ovarian pregnancy, which occurs is less than 3% of ectopic pregnancies.

It blew me away to think that I had been walking around with internal bleeding and a ruptured ovary.  After my successful round of methotrexate, I couldn't believe that there was anything left of a sizable amount that could cause a rupture.  My doctor explained to me that ovaries are really sensitive, so even if the ectopic never grew big, it could still do more damage than if it had implanted in the fallopian tube.  Without that round of methotrexate I had a week and a half ago to break up the ectopic, my body would have been in a lot more serious trouble and a lot sooner, and I would have probably ended up in emergency surgery.  I was relieved to hear that there had still been a need for the methotrexate even though I still needed surgery in the end. 

Now that all the problems have been identified and either removed or repaired, my doctor thinks I'm well on my way to a full recovery.  I'm no longer a ticking time bomb and am humbled by the knowledge that the doctor wasn't just being overly cautious when she said how serious ectopic pregnancies and the risk of rupture are.  I'm thankful now that she consulted with her colleagues and she didn't let me go home while she tried to figure out what the heck the problem was, because in her words, it would have been a matter of time before I "crumpled" if I hadn't had surgery.

I'm now waiting to be discharged from the hospital.  I'm super tired, but at least the pain doesn't seem to be as bad as it was after c-section.  Recovery from a laparoscopic surgery is a lot easier on your body since it only requires small incisions.  I hope that remains the case. I still have recovery ahead of me and have been given the same restrictions (no heavy lifting, housework, no driving while on pain medications, etc.) that I had after Oliver's and Soren's births. 

I look forward to being back at home and with my family.  I felt so lonely at the hospital without them, so it really lifted my spirits when I had visitors.  Our nanny brought Oliver and Soren to the hospital to hang out with me the morning of surgery and then Chris took over when it was time for the kids to go home for lunch and naps.  The biggest surprise was when I was wheeled back into my room after surgery and I saw Chris sitting in my room with our two little boys in his lap.  The surgery started an hour later than expected and took a lot longer than anticipated, but there was my little family patiently waiting for me. 

My validation for making Oliver brush his teeth

Yesterday's New York Times article "Preschoolers in Surgery for a Mouthful of Cavities" (reprinted below) was timely given that Oliver has recently been to the dentist.  I wasn't worried that he had a mouthful of cavities, (at least I hope not since we didn't get x-rays to double check) but given that instilling good oral hygiene habits in him has been a challenge, the article was a reminder to keep up the regimine.  And to keep after my husband, in-laws and the nanny to encourage the habits that protect teeth. 

New York Times

March 6, 2012

Preschoolers in Surgery for a Mouthful of Cavities

By CATHERINE SAINT LOUIS

SEATTLE — In the surgical wing of the Center for Pediatric Dentistry at Seattle Children’s Hospital, Devon Koester, 2 ½ years old, was resting last month in his mother’s arms as an anesthesiologist held a bubble-gum-scented mask over his face to put him under. The doctors then took X-rays, which showed that 11 of his 20 baby teeth had cavities. Then his pediatric dentist extracted two incisors, performed a root canal on a molar, and gave the rest fillings and crowns.

Devon’s mother, Melody Koester, a homemaker from Stanwood, Wash., and her husband, Matthew, an information technology manager, said they began worrying about brushing Devon’s teeth only after Mrs. Koester noticed they were discolored when he was 18 months old. “I had a lot on my mind, and brushing his teeth was an extra thing I didn’t think about at night,” she said.

The number of preschoolers requiring extensive dental work suggests that many other parents make the same mistake. The Centers for Disease Control and Prevention noted an increase, the first in 40 years, in the number of preschoolers with cavities in a study five years ago. But dentists nationwide say they are seeing more preschoolers at all income levels with 6 to 10 cavities or more. The level of decay, they added, is so severe that they often recommend using general anesthesia because young children are unlikely to sit through such extensive procedures while they are awake.

There is no central clearinghouse for data on the number of young children undergoing general anesthesia to treat multiple cavities, but interviews with 20 dentists and others in the field of dental surgery suggest that the problem is widespread.

“We have had a huge increase in kids going to the operating room,” said Dr. Jonathan Shenkin, a pediatric dentist in Augusta, Me., and a spokesman for the American Dental Association. “We’re treating more kids more aggressively earlier.”

But such operations are largely preventable, he said. “I have parents tell me all the time, ‘No one told us when to go to the dentist, when we should start using fluoride toothpaste’ — all this basic information to combat the No. 1 chronic disease in children.”

Dentists offer a number of reasons so many preschoolers suffer from such extensive dental decay. Though they are not necessarily new, they have combined to create a growing problem: endless snacking and juice or other sweet drinks at bedtime, parents who choose bottled water rather than fluoridated tap water for their children, and a lack of awareness that infants should, according to pediatric experts, visit a dentist by age 1 to be assessed for future cavity risk, even though they may have only a few teeth.

And because some toddlers dislike tooth-brushing, some parents do not enforce it. “Let’s say a child is 1 ½, and the child screams when they get their teeth cleaned,” said Dr. Jed Best, a pediatric dentist in Manhattan. “Some parents say, ‘I don’t want my little darling to be traumatized.’ The metaphor I give them is, ‘I’d much rather have a kid cry with a soft toothbrush than when I have to drill a cavity.’ ”

Dental decay often starts with a dull ache that may be mistaken for teething. That is why parents do not realize their child’s teeth are infected until they break or the pain becomes so acute that the child cannot sleep, said Dr. Joel Berg, director of the Center for Pediatric Dentistry, a joint venture since 2010 between the University of Washington and Seattle Children’s Hospital, which built a surgical wing because of the demand for oral surgery for preschoolers.

With a cooperative child, a cavity — or even many — can be treated in a dentist’s office with an injection of local anesthesia and an episode of “The Backyardigans” to distract patients.

But dentists routinely recommend general anesthesia for preschoolers with extensive problems, particularly if they will not even let X-rays be taken. The cost to parents for dental restoration under general anesthesia for a child ranges from $2,000 to $5,000 or more, depending on insurance coverage and the amount of work, several dentists said.

Dr. Megann Smiley, a dentist-anesthesiologist at Nationwide Children’s Hospital in Columbus, Ohio, is used to hearing parents question the need for general anesthesia to fix their children’s infected teeth. “It seems like putting a match out with a fire hydrant,” Dr. Smiley said. “But if any of us tried to get 12 teeth treated, we wouldn’t think that’s small.”       

The dental surgery center at Nationwide has three operating rooms, which staff members and local dentists used to treat roughly 2,525 children in 2011, 6 percent more than in 2010. The average age of patients is 4, and most have decay in six to eight teeth, she said.

“The most severe cases have 12 or 16, which is seen several times a week,” Dr. Smiley added.

Using general anesthesia on healthy children has risks, including vomiting and nausea, and, in very rare cases, brain damage or death. Using anti-anxiety drugs to relax a child coupled with local anesthesia for pain has risks, too, including an overdose that could suppress breathing.       

Hannah Schwartz of Brooklyn refused general anesthesia for her 3 ½-year-old daughter, Alice. By then, one of Alice’s eight cavities had already been treated in a dentist’s office using a papoose board to immobilize her from head to ankle with straps. Her daughter screamed, “Take it off me!” for the 20-minute procedure, said Ms. Schwartz, a nursing student.    

 

Afterward, “I left the room and burst into tears without Alice seeing,” she said, adding that she would try a third option, laughing gas.

Of course, the lack of money or insurance can be an issue, but several dentists in interviews nationwide attributed extensive cavities in part to lax parenting, at all income levels.

“It’s not just about kids in poverty, though kids of lower socioeconomic status tend to get more cavities,” said Dr. Rochelle Lindemeyer, director of the pediatric dentistry residency program at Children’s Hospital of Philadelphia and the University of Pennsylvania dental school. Affluent families may have nannies who “pacify kids by giving them a sippy cup all day,” Dr. Lindemeyer said.

Brushing teeth twice a day used to be nonnegotiable, she said, but not anymore. “Some parents say: ‘He doesn’t want his teeth brushed. We’ll wait until he’s more emotionally mature.’ It’s baffling,” she added.       

Dr. Man Wai Ng , the dentist in chief at Children’s Hospital Boston, said she heard parents, rich and poor, make similar rationalizations about their preschoolers’ snacking, like, “I can’t ever imagine Johnny being hungry, so I’m laying out a whole-wheat spread that’s always available.”

With a grant from the DentaQuest Institute, Dr. Ng started a disease-management program to alter the habits of parents of children with cavities so some could avoid the operating room. Her advice includes less frequent snacks, and only four ounces of juice a day. She does not forbid sweets, but suggests brushing afterward, and bacteria-killing Xylitol lollipops.       

Multiple studies have shown that even children who undergo general anesthesia to treat dental decay end up with cavities again. Janine Costantini, the ambulatory practice director at Children’s Hospital Colorado, said the staff treated a 3-year-old who was making his second visit to the operating room for dental work. The boy arrived with a bottle of Coca-Cola.

Oliver still hates the dentist

Oliver still hates the dentist, but he loves her waiting room with its shelves full of toys, books and puzzles, a fish tank and a floor-to-ceiling chalkboard.  After screaming and writhing through his entire cleaning, I tried making it up to him by hanging around for a bit after the appointment just so he could play in the waiting room. 

For the high-stress situation that a simple teeth cleaning turned into, the staff was wonderful.  The hygienist chatted it up with Oliver and even helped him do the puzzle he'd brought from the waiting room.  She distracted him with more toys and let him look at her computer as she simultaneously explained that she was going to take a picture of his teeth and then he'd get to see it on her computer.  Since Oliver had had a blast taking pictures with my camera a few weeks ago, I tried playing up this event, but he wasn't fooled.  Even though he got to sit on my lap in the chair, he was not going to open his mouth and hold a piece of film between his teeth and sit still enough for a usable x-ray.  At least I had gotten him to sit on my lap since a few minutes earlier, he announced he was going home and confidently walked out the door and started down the hall.

The hygienist finally gave up and called in the dentist.   In order for her to clean his teeth, we used the same set-up as last time when I sat on a stool across from the dentist, had Oliver straddle me and then I laid his head on the dentist's lap and she went to work cleaning his teeth as quickly as she could.  She expressed worry that I wasn't comfortable, but I reminded her that I was pregnant last time I had to bend forward with Oliver's body straddled across my stomach!
 
Unfortunately, the staining that had prompted me to take Oliver to the dentist six months ago had come back.  But it was all easily removed with the high-powered tooth brush.  (I know I have one dentist among my readers...I laugh wondering what she thinks of my non-technical descriptions of our visit to the dentist.)  Explaining that his enamel is probably just more susceptible to staining, she recommended we brush his teeth three times a day, instead of two.  And floss too.  She handed us some samples of some dinosaur-shaped flossers and Oliver, over the trauma of his teeth-cleaning, scampered out to waiting room.

With 16 teeth, he's four shy before we can call teething done with.  I hear those "two-year molars" (called so because they come in between 24 and 33 months) are the worst.  After some long weeks of difficult behavior - in hindsight, mostly due to teething, but also a few ear infections and cases of pink eye thrown in there - we've experienced a week of the best mood we've seen Oliver in in awhile.  It's like being in the eye of a storm.

First pediatric dentist appointment

Although it is now recommended that children first see a dentist by age one, I had always wondered how a dentist could possibly clean the teeth of an uncompliant toddler. Very quickly, very carefully and with a lot of patience for screaming I discovered.

When I filled out the form detailing Oliver's dental history and came upon the question asking if there was any other information that would be valuable for the dentist to know, I wrote, "Oliver will probably scream the entire visit."
The pediatric dentist had Oliver sit on my lap facing me with his legs straddling my waist. She put a towel over her lap and then had Oliver lay down with his head on her lap and she hunched over him and worked on his teeth. He screamed bloody murder and I had to hold the poor little guy's arms down, but she was able to examine his mouth, count his teeth, (he's up to 10!) and then even clean them. I was relieved she was able to scrub away the stains that had prompted me to finally take him for his first appointment. She finished with an application of fluoride and the whole process was over with in minutes. Oliver spent as much time calming down from the whole interaction as he did actually having his teeth cleaned.

Other than the part of having his teeth cleaned, Oliver liked everything about his visit to the dentist. He got to ride an elevator and run up and down a hallway on the way to her office and the waiting area was a toddler's dream hang-out area with its colorful kid-sized tables, chairs and arm chairs, shelves full of books and toys and a wall-size chalkboard. Oliver pointed at the chalkboard and said, "Oh, oh" and almost couldn't believe it when I said he coud draw on it. His only previous experience drawing with chalk has been outdoors on the sidewalk. He started to cry when we went back to the exam room, but there was another bucket of toys waiting for him and before we left, he got to pick a toy out of the stash in the Radio Flyer wagon stowed behind the receptionist's desk. He wanted to look at and handle each kind of toy, but finally settled on a car.
Oliver's visit to the dentist was as humbling for me as it was reaffirming. Chris and I hadn't bothered putting Oliver on our dental plan, because we originally thought dental insurance for a baby was pointless. (And this is from someone who believes whole-heartily in preventative care.) But how quickly they sprout a bunch of teeth and grow up into little kids.

It was nice to hear that some of the habits I've been a stickler about enforcing (no juice, milk only at meal times, getting rid of the bottle) actually make a difference. (I came clean that Oliver still uses a pacifier, but thankfully didn't receive a lecture about that.) But I learned that despite thinking I was doing the whole teeth-brushing thing properly with Oliver, I could be doing it better. I had been trying to walk that fine line between letting Oliver "brush" his own teeth (really all he does is suck on the toothbrush) and helping him afterwards, but without pushing too hard for fear I'd create a bad association with brushing. The result was improper brushing that allowed grayish/brown staining to form along the top portion of his teeth (main culprit was probably fruit, especially berries). A really thin layer of clear, gum-like tissue had made it difficult for the bristles to properly brush near the gum line. In addition to recommending I bite the bullet and buy Oliver a high-quality electric toothbrush because it's more efficient, she showed me how to hold Oliver so I could brush his teeth better. Let's just say that Oliver has not taken willingly or quietly to the more thorough brushing routine, but I'm hoping, hoping he adjusts soon.

Renewed Gym Membership

At 22 pounds, Oliver is like one large, wiggly free weight and if I have any muscle tone left in my body after giving birth to him, it's the result of the heavy-lifting I do on a daily basis - the hoisting of baby onto the changing table and in and out of a car seat, balancing baby on my hip while trying to do a myriad of household tasks one-handed, or throwing baby up in the air to elicit smiles. I was clearly not out of shape, but 15 months after Oliver was born, I hardly felt in shape. So a week before Christmas, I finally caved and rejoined the gym.

I had been a near-daily runner, with a smattering of other sports thrown into my weekly activity mix, mainly soccer and cross-country skiing, depending upon the season, when Chris and I joined the gym together. I thought I would be intimidated by the body builders, but after some pointers from Chris and a trainer, I found my own routine in the weight room and discovered I liked weight-lifting.

Even when I became pregnant, I kept going to the gym through the end of my second trimester. But then summer was well underway and I preferred being outdoors, and by that point, well, I was big and uncomfortable. We were moving anyway. So I let my membership lapse.

Like any other new mom, I wanted to get back in shape. Through good diet and a commitment to physical fitness, I had worked my way to the best shape of my life before getting pregnant - without a gym membership - and I was determined to do it all over again. I would work with what I had or could manage, which really was just a few free weights, a mat and a stroller to take the baby with me walking. Besides everyone was telling me that chasing after your kid is forced exercise in itself.

So why did I end up joining the gym (and declining the childcare option)? I had been fairly active with Oliver by putting lots of miles on the stroller, but frankly, exercising with a baby is pretty limiting (especially during winter in Minnesota). And it was unsatisfying. You can't get a runner's high from walking. We were given a hand-me-down jogging stroller, but I have yet to use it, (and neither has Chris, for the record) because running while pushing a stroller sounds 100% unappealing. Running was a stress-reliever for me and getting a baby ready, getting a stroller out, hoping the baby doesn't get hungry or soil his diaper en route, stopping to check on baby and pushing all that extra weight and having your gait thrown off by running with one hand attached to a bar was not my idea of a stress-reliever. Nor were classes like stroller strides or baby yoga, or any other gimmicky "exercise" class designed to do with your baby. I wanted uninterrupted, kid-free exercise I could do at my pace.

I had been reluctant to rejoin the gym because a membership felt like an extravagance when there were other ways to get exercise (even if I discovered that many of my exercise plans for post-pregnancy were impractical) and I didn't think I would get my money's worth given how seldom I would be able to go. But while most of what I do at the gym could be replicated elsewhere, I finally accepted that getting myself out of the house for some solo uninterrupted exercise time was good for both my physical and mental health.

Most days my only form of cardiovascular exercise is still walking with the stroller (and more often at the mall than I ever thought would happen) and I'm thankful for that time to be active. I still think it's important to get outside and "exercise" with your kids, because it's modeling a healthy, active lifestyle and in most cases, gets them outdoors. But I've learned that your exercise routine isn't all about you - it's got to be geared towards your kids. They'll only want to spend so long strapped in a stroller or pulk sled before they want to do something else - eat, run around, go inside where it's warm. So even though I consider it a good week if I have time to go to the gym twice, those are two nights I come back home feeling a tad bit more fit and remarkably more relaxed.