Category Archives: pregnancy

science gone wrong, pt 1: are vaccines really causing higher infant mortality rates?

This study, purporting to show that greater numbers of vaccines in the first year of life are associated with greater risk of infant mortality, came across my radar recently. I thought I’d take a moment to look at it in part of a series of posts on the emotionally fraught relationship between science and our everyday lives. This post is the one that has the most to do with parenting; the ones that follow will be more about a health scare I had recently and some of the changes it’s wrought on our life.


Neil Miller and Gary Goldman claim to have found a correlation, on a population scale, between the number of vaccines children receive in the first year of life in a given country and that country’s infant mortality rate. (Full text of the paper in PDF here.) Their work is riddled with conceptual and procedural problems, and of course whenever someone asserts a correlation without establishing a concrete causal mechanism, we should be skeptical. (Using the phrase “synergistic toxicity” over and over again does not count as establishing a causal mechanism.) But since this kind of “research” frequently gets turned into news items that get circulated among worried parents trying to make good decisions for their kids, I thought I’d delve into it a little bit, leaning gently on a couple of excellent analyses from David Gorski at Science-Based Medicine and Catherina at Just The Vax.

A summary of the problems addressed by Catherina and Dr. Gorski:

1. The paper is inconsistent in its definition of a “dose.” Catherina lays it out neatly:

[T]he way Miller and Goldman are counting vaccines is completely arbitrary and riddled with mistakes.

Arbitrary: they count number of vaccines in US bins (DTaP is one, hib is separate) and non-specific designations (some “polio” is still given as OPV in Singapore), rather than antigens. If they did that, Japan, still giving the live bacterial vaccine BCG, would immediately go to the top of the list. That wouldn’t fit the agenda, of course. But if you go by “shot” rather than by antigen, why are DTaP, IPV, hepB and hib counted as 4 shots for example in Austria, when they are given as Infanrix hexa, in one syringe?

Mistakes: The German childhood vaccination schedule recommends DTaP, hib, IPV AND hepB, as well as PCV at 2, 3 and 4 months, putting them squarely into the 21 – 23 bin. The fourth round of shots is recommended at 11 to 14 months, and MenC, MMR and Varicella are recommended with a lower age limit of 11 months, too, which means that a number of German kids will fall into the highest bin, at least as long as you count the Miller/Goldman way.

(If you’re bored and want to check their work, here are the vaccine schedules from Europe that Miller and Goldman claim to have relied on. They cite UNICEF’s website as their source for non-European countries, although, since they don’t provide a URL for a specific page on the site, I’ve been unable to find that data.)

The definition of a “dose” is critically important here. If you want to entertain the hypothesis that vaccines are in some way “toxic” because of, for example, preservatives or other foreign material, then the number of antigens matters less than the number of shots or vials. On the other hand, if you want to say that the antigens are the toxic substance, then as Catherina points out you have to account for different levels of antigens in different types of vaccines for the same diseases. Miller and Goldman’s vague and confusing approach does little to tease out or account for these differences.

2. Countries don’t all count dead infants the same way. Dr. Gorski quotes Bernardine Healy, former director of the NIH:

[I]t’s shaky ground to compare U.S. infant mortality with reports from other countries. The United States counts all births as live if they show any sign of life, regardless of prematurity or size. This includes what many other countries report as stillbirths. In Austria and Germany, fetal weight must be at least 500 grams (1 pound) to count as a live birth; in other parts of Europe, such as Switzerland, the fetus must be at least 30 centimeters (12 inches) long. In Belgium and France, births at less than 26 weeks of pregnancy are registered as lifeless. And some countries don’t reliably register babies who die within the first 24 hours of birth. Thus, the United States is sure to report higher infant mortality rates. For this very reason, the Organization for Economic Cooperation and Development, which collects the European numbers, warns of head-to-head comparisons by country.

Miller and Goldman claim to have accounted for these differences and quote a CDC paper which says that “[I]t appears unlikely that differences in reporting are the primary explanation for the United States’ relatively low international ranking.” Of course, this statement in itself is quite vague, giving no idea what percentage of the difference in rankings the reporting problem plays. But it also begs the question, “What is the primary explanation?” The same CDC paper gives a perfectly reasonable answer, to which we shall return later.

In the meantime, this paper commissioned by the Congressional Budget Office on the subject of America’s seemingly awful infant mortality stats provides more detail on the difficulties of accurately comparing IMRs:

In countries where physicians are more aggressive about attempting to resuscitate very premature newborns — of which the United States is probably the leading example — extremely small neonates are more likely to be classified as live births than in countries with less aggressive resuscitation policies. Thus, for example, if little attempt is made to resuscitate newborns weighing less than 500 grams (1 pound, 2 ounces), these births may be classified as fetal deaths and not be included in either the live birth or the infant mortality statistics. By contrast, when attempts are made to resuscitate the tiniest newborns, they are more likely to be classified as live births, although most will subsequently die and then be included in the infant mortality statistics.

(We’ll get back to this idea of aggressive treatment in the final section.)

3. Miller and Goldman selected data from a single year, 2009. But why? Surely an analysis over multiple years, or multiple decades, would be more useful. We could be more certain that the IMRs in 2009 weren’t some sort of statistical fluke. And we could watch IMRs move (or not) according to changes in vaccination schedules. As Catherina points out,

For example, in the early 1980ies, Germany’s infant mortality was about 5 times as high (10000 infants died per year) than it is today (2000 died in 2009 with approximately the same birth rate), however (in Miller’s and Goldman’s twisted logic), the vaccination schedule contained far fewer vaccines in the first year (essentially just DT and polio, since the whole cell pertussis was not given between 1974 and 1991, the aP not yet introduced, the MMR given in year 2, no hib, nor hepB, nor PCV given either), while Germany was already very much a “developed country”.

4. Miller and Goldman do not consider the whole world. It’s tempting to say that they’re on stronger ground here — that you want to compare wealthy, industrialized countries to other wealthy, industrialized countries. But they don’t seem to be particularly interested even in other industrialized and/or wealthy countries whose IMRs fall below that of the U.S. — say, countries in Eastern Europe, or the wealthy Arab states — to see whether their correlation holds up further down the list. Gorski:

[S]ince the focal point of the analysis seems to be the U.S., which, according to Miller and Goldman, requires more vaccine doses than any other nation, then it would make sense to look at the 33 nations with worse IMRs than the U.S.

Be that as it may, I looked at the data myself and played around with it. One thing I noticed immediately is that the authors removed four nations, Andorra, Liechenstein, Monaco, and San Marino, the justification being that because they are all so small, each nation only recorded less than five infant deaths. Coincidentally, or not, when all the data are used, the r2=.426, whereas when those four nations are excluded, r2 increases to 0.494, meaning that the goodness of fit improved.

In other words, even among the countries above the U.S., Miller and Goldman cherry pick the data, dropping small countries that don’t make the data fit the way they want it to. (4 countries out of 33 is an 8th of the data being excluded, in case you were counting.)

Are these decisions reasonable? Would including Russia or Andorra have made the data clearer, or muddied the waters? I’m not sure, but in light of other methodological decisions, this is questionable at best.

5. What’s with the grouping? Why sort the countries into groups based on the number of vaccines, and then plot the average IMR of each group, instead of just plotting all the data points separately? Gorski again:

[F]or some reason the authors, not content with an weak and not particularly convincing linear relationship in the raw data, decided to do a little creative data manipulation and divide the nations into five groups based on number of vaccine doses, take the means of each of these groups, and then regraph the data. Not surprisingly, the data look a lot cleaner, which was no doubt why this was done, as it was a completely extraneous analysis. As a rule of thumb, this sort of analysis will almost always produce a much nicer-looking linear graph, as opposed to the “star chart” in Figure 1. Usually, this sort of data massaging is done when a raw scatterplot doesn’t produce the desired relationship.

Indeed. Of particular note is Group 2, countries with a vaccination schedule of 15-17 “doses” in the first year. Group 2 only includes 5 countries, and one of those countries is Singapore, which has the best IMR in the world (2.31) and calls for its infants to receive 17 vaccines doses in their first year, according to Miller and Goldman’s counting. Because Group 2 is so small, Singapore is clearly dragging down the average IMR of the whole group — from 4.30 to 3.90. Take out Singapore, which is clearly an enormous outlier, and Group 2 has about the same IMR as Group 3, which makes the linear relationship a lot less neat. Also, 4.30 is very similar to Denmark’s 4.34, and Denmark only requires 12 vaccines in the first year. And speaking of Singapore, if this linear correlation based on vaccination schedules is so strong, why does Singapore have such a drastically low IMR with 17 vaccine doses in the first year, when Italy and San Marino have drastically high IMRs (5.51 and 5.53, respectively) with only a single dose more (18) per year? Naturally, there will be outliers in any linear regression, but it seems that when you get done smoothing out the outliers here by dropping data points and sorting the data into bins, you’ve essentially hidden half the statistical reality.

6. They fall prey to the “ecological fallacy.” Gorski once more:

The ecological fallacy can occur when an epidemiological analysis is carried out on group level data rather than individual-level data. In other words, the group is the unit of analysis. Clearly, comparing vaccination schedules to nation-level infant mortality rates is the very definition of an ecological analysis.

In other words, measuring correlations between variables on the population level tells you nothing about the correlation on an individual level, and indeed is likely to vastly overstate the likelihood of such a correlation. For example, let us suppose that Italians have fewer heart attacks than do Englishmen, and yet eat pasta at a much greater rate. Can we conclude that pasta is preventive against heart attacks? No, because, among other things, you haven’t demonstrated that the pasta-eating individuals in the Italian population are the ones getting fewer heart attacks. Perhaps there’s a smaller subset of Italians who eat hardly any pasta at all, yet get plenty of vigorous exercise, and therefore drag down the national average incidence of heart disease.

Similarly, if you want to find out if a heavier vaccine schedule in the first year correlates with higher infant mortality — or, to be even more specific, whether it correlates with higher rates of SIDS, since Miller and Goldman argue that SIDS and unexplained deaths caused by vaccine “toxicity” are probably the real culprit here — you should do a study following outcomes for individual kids who receive different schedules of vaccines. Trying to track a phenomenon, if there is one, by comparing different whole populations is both inefficient and brutally error-prone.

To their credit, Miller and Goldman attempt to address this problem in a section titled “Ecological Bias.” To their discredit, their explanation is simply awful:

Although most of the nations in this study had 90%–99% of their infants fully vaccinated, without additional data we do not know whether it is the vaccinated or unvaccinated infants who are dying in infancy at higher rates. However, respiratory disturbances have been documented in close proximity to infant vaccinations, and lethal changes in the brainstem of a recently vaccinated baby have been observed. Since some infants may be more susceptible to SIDS shortly after being vaccinated, and babies vaccinated against diarrhea died from pneumonia at a statistically higher rate than non-vaccinated babies, there is plausible biologic and causal evidence that the observed correlation between IMRs and the number of vaccine doses routinely given to infants should not be dismissed as ecological bias.

[emphasis mine]

So after admitting that they have in no way correlated these higher rates of infant mortality with actual vaccination on the individual level, Miller and Goldman attempt to razzle-dazzle the reader with a lot of scary-sounding stuff. But, for example, the “lethal changes in the brainstem” occurred in a single child after a vaccination — to infer anything from that would be a classic case of “post hoc, ergo propter hoc” reasoning. I’m sure you can find a single case of a child who died of bullet wounds after being vaccinated, too.

And the babies who died of pneumonia at a statistically significantly higher rate after receiving the rotavirus vaccine? That was in a single study out of eight studies conducted on the safety of Rotarix, the vaccine in question. When you compile all eight studies, the relative risk of pneumonia between Rotarix and placebo is exactly 1, according to this exhaustive FDA briefing (PPT — skip to slide 59).

I’m not going to bother batting at the other examples, but you see where this is going. And the problem of the ecological fallacy is probably the most damning, because even if all the other problems in this paper were fixed, this alone would be enough to keep it from making any sense as science.


Finally, I’d like to discuss that CDC report I promised to come back to, and pile on a criticism of my own that neither Catherina nor Dr. Gorski really dealt with. Namely, we know the risk factors that bring the U.S.’s IMR up. Alice Park discusses them in a 2009 article for Time:

Starting in 2008, the March of Dimes began tracking three of the major contributors to the high preterm birth rate — lack of insurance among women of childbearing age, rates of cigarette smoking and the rate of babies born preterm, but at the tail end of pregnancy, between 34 and 36 weeks….

By far the biggest contributor to the high premature birth rate is the rate of so-called late-preterm births. About 70% of babies born too early in the U.S. are born between 34 and 37 weeks. There are many reasons for these early deliveries, making it particularly difficult to target one or even a few factors and address them head-on. The increase in multiples — twins, triplets or more — is one contributor. The rise in assisted reproductive technologies, such as in vitro fertilization, is another; these techniques are associated with both an increased risk of multiples as well as a higher risk of premature delivery, even of singletons….

This is relatively undisputed, as far as I can tell from reading through literature on America’s woeful infant mortality rate. What do Miller and Goodman make of this? From the paper:

Preterm birth rates in the United States have steadily increased since the early 1980s…. Preterm
babies are more likely than full-term babies to die within the first year of life. About 12.4% of US births are preterm…. Preventing preterm births is essential to lower infant mortality rates. However, it is important to note that some nations such as Ireland and Greece, which have very low preterm birth rates (5.5% and 6%, respectively) compared to the United States, require their infants to receive a relatively high number of vaccine doses (23) and have correspondingly high IMRs. Therefore, reducing preterm birth rates is only part of the solution to reduce IMRs.

There are several squirrelly points packed into this paragraph. First, note the phrase “within the first year of life,” which, while part of a technically correct definition of infant mortality, leads us to the question: why are we counting all deaths in the first year in this study anyway? Surely the correct measure of whether vaccines influence mortality would exclude all deaths prior to the first vaccine — i.e., all deaths that occur at or immediately after birth.

Second, the cherry-picking of Ireland and Greece as countries with low preterm birth rates and high IMRs, and then imputing those figures to vaccination rates is obviously putting the cart before the horse. If you’re trying to draw correlations of this kind, why not include a table of preterm birth rates and use them to factor out that difference in IMRs before trying to measure a difference attributable to vaccine schedules? I mean, if you have those preterm birth rates handy, which Miller and Goldman seem to, although they don’t provide a footnote for the Ireland and Greece numbers.

Anyway, here’s an interesting graphic from that CDC paper Miller and Goldman cited to show that reporting differences did not account for the bulk of the difference in IMRs. It shows what the US infant mortality rate would look like if we had Sweden’s level of preterm births:

What does this tell us? It tells us that, exactly as the CDC, the CBO, and the March of Dimes have concluded, much of the difference in IMR between the U.S. and other countries can be attributed to pre-term birth rates. And what does that tell us about this supposed correlation between vaccination and IMR?

It tells us that having an aggressively interventionist medical culture in the U.S. leads, somewhat paradoxically, to higher IMR. Remember that many of those preterm births are the result of fertility treatments. And U.S. physicians are more aggressive about attempting to resuscitate very small babies, even though most will die anyway; this leads to a much higher count of live births followed by death than in countries that treat those unbreathing preemies as still births. And aggressive monitoring of fetal health, and a greater willingness to either induce early labor or perform caesareans, may also play a role.

And then there’s this interesting paper from the New England Journal of Medicine that finds that, paradoxically, the rapidly increasing numbers of new neonatal ICUs in the U.S. may be responsible for at least some of the rise in infant morbidity and mortality:

In regions with a greater supply of beds and neonatologists, infants with less serious illness might be more likely to be admitted to a neonatal intensive care unit and might be subjected to more intensive diagnostic and therapeutic measures, with the attendant risks of errors and iatrogenic complications, as well as impaired family–infant bonding.

In short, if there is a correlation between vaccination schedules and IMR — a fact not proven here — there may be a simple explanation (e.g., a more aggressive approach to medicine overall) that does not require invoking unproven and unexplained “toxicity” in vaccines.


Where does all this leave us, in terms of what I was talking about at the beginning, the relationship between science and our everyday lives? Well, it counsels skepticism, certainly, when “news” of a disturbing “scientific” discovery shows up on parenting forums or in our inboxes. And of course it challenges each of us to become more scientifically literate in our reading — which is why I occasionally undertake these close examinations of scientific subjects related to parenting.

But this process is exhausting. To really delve into this paper, to take it apart and understand it to my own satisfaction, has taken two days and 3500 words. I can’t possibly do this with each piece of scientific information (or misinformation) that comes my way. For the most part, I’m forced to shrug and rely on professionals at the CDC, the FDA, and the doctor’s office to steer me the right way. But what happens when the professionals start to seem untrustworthy or themselves misinformed? What do you do when your need for expert knowledge is undermined by an almost paranoid sense that the experts are not on your side? And how do you avoid going too far in the other direction and falling victim to things like vaccine denialism?

I’ll try to talk more about that in the next couple of entries in this series.

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Maybe “coded” means, like, “ordered lunch in”.

As you may have gathered, they let me leave the hospital! I was super-gleeful about this, because HOSPITALS ARE TERRIBLE (don’t get me wrong, if you need your life saved, they will take care of that for you. But they are also sort of unpleasant places where doctors wake you up at 6:45 AM to tell you complicated things about the HOLE THEY PUT IN YOUR THROAT and how OH YEAH THEY MIGHT HAVE DESTROYED YOUR ABILITY TO SPEAK.) but then I started to realize that leaving the hospital has as its main downside that you expect to be Significantly Better and like Able To Go Shopping or whatever, when really at first you need 18 hours of sleep a day.

(Still better than being in the hospital, though.)

At this point, I am mostly all better: they took out the valve in my throat, and my voice came back, so I will just have a cool scar to freak people out with (after the hole closes up. YES! I still have a small hole in my throat. Jealous?) And they put me on medication for a while to make sure I don’t have any further bizarro incidents where my blood pressure becomes 900/500 or what have you… And antibiotics so I don’t get MRSA and die (I imagine.)

So ignoring minor issues like near-constant exhaustion and this thing where my memory suddenly doesn’t work (which better be because of the exhaustion and not because I blew a fuse in my brain, you guys!), I am pretty much back to normal. Aside from how I now have this baby.

***

When I first woke up, the day after The Dramatic Incident, I remembered essentially nothing*. So as I slowly regained consciousness, nurses and doctors would come in and talk to me and as hours passed, I slowly gathered the following: these people seemed to think that I was married and had been pregnant and had almost died and had just had a baby.

HOLY SHIT WHAT THE FUCK?!?

I did not believe any of this.

You guys! It was like one of those ’60s paranoid conspiracy thrillers, where a guy wakes up in an apartment he doesn’t remember and has a wife he doesn’t remember and then eventually it turns out that it’s all a ploy by the Russians to get the nuclear football or something. And exactly like that guy, the longer it went on, the more I started to doubt EVERYTHING IN THE WORLD.

The basic timeline is something like so: I woke up doped to the eyeballs on painkillers and sedatives, people implied that I had a kid, and then crammed me into a wheelchair and took me up a bunch of floors to see some tiny person who evidently lived full-time in an EZ-Bake oven.

“Here’s your son! Isn’t he beautiful?”

Riiiiiiiiiight.

I THINK I WOULD REMEMBER IF I HAD BEEN PREGNANT, LADY. NICE TRY.

Later, when Seth made his illegal foray into checking out the folder of records the NICU staff were keeping on us, the notation for my first visit was:

MOTHER HAS FLAT AFFECT.

This was pretty much the one thing about the hospital that actively pissed me off. Flat affect! Are you kidding? I was stoned out of my gourd, remembered nothing, and was UNABLE TO TALK. BECAUSE OF THE TUBE IN MY THROAT. That wasn’t “flat affect”, that was “skepticism”.

Grumble.

(The NICU nurses were actually really outstanding specimens of humanity. It was just that one thing that made me cranky. No wonder they won’t let parents look at their records.)

***

Seth has mentioned previously that hospitals are not necessarily as organized with the imparting of information about your care as you might think. I guess, insofar as I had ever thought about this stuff, I imagined that if you were in the hospital for something life-threatening and you were totally out of it, doctors would probably wait for your husband to be around before discussing complicated health stuff with you. (Particularly if you couldn’t talk to ask them questions.)

Not so! The doctor who crammed the tube through my throat, for instance (PS, I first met this guy in the ICU, and for quite some time I thought maybe he was someone I was hallucinating and had cobbled together from from The Simpsons characters.) liked to walk in at 6:22 AM and say things like “So we’re not totally sure your voice is going to come back! {jargonjargonjargonjargon} Some other doctor is going to {jargonjargonjargon}, okay? How’re you feeling? Good, good. All right, see you later! Oh, hey- don’t forget to {jargonjargon something really complicated involving breathing}.”

THEY WERE ALL LIKE THIS. I kind of thought that leaving the hospital would mean the end of this nonsense, but NO:

Today we took Henry (who has been allowed to come home from the hospital – Seth will probably update you on that later when we are no longer sobbing with exhaustion**… or I guess if you’re a parent yourself you can just think back to the early days and laugh at us for being SUCKERS.) to the pediatrician for the first time.

(He is totally fine and healthy and gets excellently angry when nurses try to take his pants off: OUTRAGE! VENGEANCE WILL BE HIS. But that’s not what this story is about. Sorry, baby-oglers.)

The pediatrician had one of those electronic readers she used to flip through our various hospital records. She said things like “Wow! What a dramatic experience!” and Seth and I nodded politely: we have figured out over the past few weeks that having full-blown, no-warning eclampsia makes you the obstetrics version of reality-tv-show-“famous”.

And then she tapped a new section of the screen and said, in awesome deadpan:

“Huh. So you coded on the table?”

And I said “I’m sorry?” and looked at Seth – you know, just in case he had been Keeping Things From Me – and he was shaking his head, “No, I don’t think so–”

And the doctor said, firmly and just ever-so-slightly dismissively – BE QUIET CIVILIANS, DO YOU THINK I DON’T KNOW HOW TO READ A MEDICAL RECORD OR SOMETHING?!? WHO’S THE EXPERT HERE? – “Yep, that’s what it says, all right. Coded on the table. Phew! What an ordeal, huh?”

You would think – or I would have thought – that this is something that maybe someone would have mentioned to me! BUT NO.

(???)

Of course I also recently discovered that the reason my midsection is crazy sore is not because I am having EXPLODING SPLEEN SYNDROME but instead because the two surgeons who saved me and my kid used that area to rest their heavier instruments while they were working. So I am starting to think that my standards for how doctors communicate is based on the wrong TV shows – E.R. instead of, say, Scrubs.

*You know… except for how I suddenly had all this insight into the true nature of reality and the universe and our immortal souls, etc. Which I guess is kind of par for the course if you CODE ON THE TABLE.

**I realized that I really needed to take a freaking nap and calm down when I found myself almost-tearfully wanting to argue with Facebook. My husband had updated his FB status to indicate that he had kicked me out of the bedroom to go sleep in the TV room for a few hours (he initially kicked me out onto the couch… but I could still hear the existence of other people from the couch, so I couldn’t sleep, because WHAT IF THE BABY WERE CHOKING OR BEING ABDUCTED BY ALIENS). And instead of just going “Yep. My husband is a pretty cool guy.” I started to get argumentative and upset because he said that I had had FIVE hours of sleep, when I was pretty sure it was no more than THREE.

Not-sleeping! It’s terrible and turns you into a loon.

in the blink of an eye it can all go awry

Since Elana and I have both written about our laissez-faire, play-the-numbers approach to birth and its attendant risks, I figure we should give equal time to the tiny minority of cases where disaster strikes, natural childbirth is impossible, and only high-tech, highly interventionist medicine can save both mother and child. To this point — the story of our lousy, amazing week, in which Elana and the Lentil both almost died.


Tuesday morning, Elana got up and announced that her vision was blurry. We knew that was a possible symptom of high blood pressure, which isn’t good for pregnant ladies, so we called the OB/GYN’s office and asked them if that was the kind of thing that, you know…. They told us we weren’t being paranoid and we should get in the car and come on in. While we were getting dressed, Elana asked me to help her to the toilet, because she thought she might throw up.

She still couldn’t see very well and kept bumping into walls, which was pretty funny, so I laughed at her a little and helped steer her into the bathroom. She seemed a little unsteady, so I put a hand on her back. She reached back and brushed at my hand with her own. At first I thought she just didn’t need the extra touch (you know, sometimes too much contact is annoying, first thing in the morning), so I let go. But there was something odd about the way her hand was slapping at her back. She turned towards me, and I saw her other hand starting to curl up like a weird clawed fist. Her mouth was open in a peculiar “O” shape, and she stumbled toward me.

From all this, I cleverly deduced that Something Not So Great was happening.


When you’re in the Army and you’re about to Go Off To War, they make you take a class called “Combat Lifesaver,” in which you learn how to do things like apply a tourniquet and put in an IV, and where they teach you acronyms like

Massive bleeding
Airway
Respiration
Circulation
Head injury

They also teach you how to do buddy carries:

Buddy Carry 1

Also works on drunks.

Buddy Carry 2

I think this one is about breast cancer screening.

Which is to say, the impression you get of first aid in the Army is that you should stop any obvious bleeding and then pick the person up and haul ass to the medevac point.

So when the EMTs have been in your house for twenty minutes already and there are seven of them trying to figure out how to move one gurgling pregnant lady out of the upstairs bathroom, you want to scream, “WHAT THE FUCK IS WRONG WITH YOU??!! YOU TAKE THE LEGS, I’LL TAKE THE FUCKING SHOULDERS, AND WE GET HER DOWN THE FUCKING STAIRS!” But you don’t, because apparently these people are professionals, even though you saw one of them looking in the handbook under the chapter heading “Holy Shit — A Pregnant Lady Is Seizing!” And even when they later bump your wife into a wall and almost drop her on the way down the stairs, you resist the urge to punch anyone, because, you know, they’re saving lives here, so you try to be grateful.

Anyway, I’m pretty sure there’s more to real-deal, civilian emergency response than belt-dragging a guy to a helicopter, so I want to thank Kevin of the LaFayette Fire Department and all the other EMTs who showed up. (Seriously, it was like an ambulance convention on our street.) You guys rock.


Props, also, to my dad, who’s a registered nurse and was first on the scene. Not a lot he could do alone and without any equipment, but he at least knew what to tell the 911 operator.

Whereas I was all, “I think she’s having a stroke or a seizure or… something?” And then I thought about the time I was working on a reality TV show and one of the participants had a seizure. Or was it a stroke? Fuck.


I’m not usually a guy who falls apart in emergencies, and I didn’t fall apart right away there, either. I mean, I didn’t drop her when she fell, and I got somebody to call 911, and I corralled people and stuff out of the way while the EMTs worked. But somewhere on the ride to the hospital, I began this wave-upon-wave surge of crying that didn’t stop for several hours. I found myself crying in the front seat of the ambulance, crying in the ER, pulling myself together in the bathroom, then crying again when they showed her to me after the surgery. I kind of, sort of, usually managed to hold it together whenever she was awake — but then I’d cry again whenever I could get away. Jesus, the whole thing just knocked all the man out of me.


I mentioned “surgery.”

It’s funny — when you watch a lot of House, M.D., you sort of get the impression that they come to you and say things like, “We have to do an emergency C-section to save her life.” And you as the husband look grave and concerned and say, “Doctor, are you sure?” And then they say, “Yes, it’s the only way.” And you scrutinize them, trying to decide if you can trust them, and then you sign the clipboard and they sprint away to the OR to scrub in.

What ACTUALLY happens is your wife goes in one ambulance and you go in another and when you get there somebody makes you sign into the hospital and provide insurance information. Then you sit in another room for ten minutes, and then they come to you and say, “This is the doctor who’s going to take care of her — now why don’t you wait upstairs?” Then eventually some other people come to you and say, “Well, both mom and baby are fine after the surgery. We decided to put in tracheostomy in her throat, and she’s on a heavy sedative…” and about ten minutes later you realize that “surgery” means a C-section and that somewhere in this hospital is a baby with your name on it.

Then a sheepish-looking person asks you to sign some papers saying it was okay to do the stuff they already did.

And that is how those choices are made.


It turns out my wife had eclampsia, the very rare end state of the somewhat more common pregnancy complication preeclampsia. You can read Elana’s take on it here. Or you can read the always-funny Natalie Dee’s description of her experience. It’s a fucked-up, fucked-up thing, and scientists don’t know what causes it. Though there are some interesting theories.


We are all very well now, thank you. Somewhere in the world tonight there’s a beautiful baby boy named Henry who makes hilarious faces and eats like a champ, if you go by the neo-natal ICU staff’s encouraging words. He sometimes looks like this:

The Lentil

The Lentil, out of the womb and ready to rock!


In front of the Catholic hospital where they saved my wife and my boy stands this statue, dedicated to St. Joseph The Worker:

According to americancatholic.org’s Saint-Of-The-Day article about Joseph the Worker,

In a constantly necessary effort to keep Jesus from being removed from ordinary human life, the Church has from the beginning proudly emphasized that Jesus was a carpenter, obviously trained by Joseph in both the satisfactions and the drudgery of that vocation. Humanity is like God not only in thinking and loving, but also in creating. Whether we make a table or a cathedral, we are called to bear fruit with our hands and mind, ultimately for the building up of the Body of Christ.

Or, as Johnny Cash once said,

“If you were a baker, and you baked a loaf of bread and it fed somebody, then your life has been worthwhile. And if you were a weaver, and you wove some cloth and your cloth kept somebody warm, your life has been worthwhile.”

It’s hard for me to think of people that applies to more than the nurses who have taken such amazing care of my family in this hour of near-disaster. Also the doctors, for whose life-saving knowledge and skill I’m eminently grateful. Truly — what a miraculously gifted group of people.

But it’s the nurses who wash people’s helpless bodies and answer their questions and hold their hands and patiently gather the statistics that make scientific medicine possible. Nurses bring you juice and drugs and chairs for your visitors and say sweet, cheerful things about how good you look. Nurses are your first line of defense against parents and spouses and doctors and other patients and the bewildering changes in your normally reliable physical system and loneliness. There’s no more blessed job anywhere.

I want to bake them all cookies, but I am embarrassed by the smallness of the gesture compared to the magnitude of what they do. Maybe someday when I’m really wealthy, I’ll come back and donate a nice break room with a Wii and a 24-hour-a-day chair massage service. I don’t know — I’m just spitballing here.


POST SCRIPT: Yeah, yeah, I know — our story is a perfect illustration of how important health coverage is and how you could be ruined in an instant without it. My dad and I spent a few minutes idly calculating the total cost of this freak occurrence, and we expect it’s somewhere in the neighborhood of a quarter of a million dollars. Back when we first got pregnant, there was a brief period where we considered just playing the odds and planning on paying cash for the birth. As my sister pointed out, we would have blown that cash reserve on the ambulances alone. So yes, without government-sponsored, government-regulated health coverage, we would have been financially ruined. (Which would also have cost me my security clearance, and therefore every last one of my career options. Which would obviously have ruined us further.)

But shit, man… this blog ain’t always about why a single-payer health care system would be better. Sometimes it’s just about us.

PIGS

HIBERNATION:

Seth has replaced the header with pictures of pigs being trotted around the ring of the Alameda County Fair. He did this not because we ourselves are especially piglike (hush!), but because we went to that fair and enjoyed doing things like “looking at pigs being trotted around a ring” and “watching in total amazement as a dad insisted his rightfully-concerned children cram their little fingers in pig mouths, all while saying ridiculous things like “Pigs don’t bite! WHAT ARE YOU AFRAID OF YOU PUSSY.””

HOWEVER, speaking of being piglike. Let me tell you something, people. You spend the first trimester being unable to eat (tragedy! because of how much you like food!), the second trimester feeling smug about your fairly sensible vegetable-to-bacon ratio, and then it all comes crashing down in the third trimester, when suddenly your brain gets very, very interested in food. Some of it must be hormonal (I am clinging to this belief, thank you) but I am also blaming this sudden-onset food obsession on the fact that we just arrived here at Seth’s ancestral homestead, where it is approximately one million degrees colder than it is in L.A. – so I think that my brain is all “HOLY CRAP! Winter is coming on with a fury. We better bulk up and prepare to hibernate.”

I like this theory because of how it explains both my sudden need to eat ALL THE FOOD THERE IS and to sleep 14 hours a day. Seth says polite things like “Well! You’re building a person from scratch. I’m pretty sure eating and sleeping a lot are okay, considering.” – but, you know. I think I’ve been awake about 13 hours today. I was ready to go back to sleep about two hours ago. And I have probably eaten about six times today. Embarrassing! Also I would totally eat like a grilled-cheese sandwich RIGHT NOW if someone handed me one. Like I said… EMBARRASSING.

RATTLESNAKES:

Here is a picture from our trip! It’s of the (so far as we could tell) Only Rest Stop In Texas. It was INCREDIBLY FANCY. It was clean and new and sparkling, like an airport restroom in a nice, non-crappy airport. It has tornado shelters! It had interactive displays! (It also had signs admonishing people not to “dispose of bags of urine” in the toilets… but I’m guessing that truckers get desperate, so not really the rest stop’s fault.)

IMG_1310

It was getting all twilighty, so I failed to get a picture of this, but the rest stop also included a really awesome playground surrounded in lovely rocks-and-native-plants landscaping. Signs inserted in the landscaping warned for rattlesnakes, and urged us to stay away from rocks and tall weeds. Such as those used to landscape around the playground. For instance. You’ve gotta be tough to survive a childhood in Texas.

WHINE ON YOU CRAZY DIAMOND:

We will have to find a new doctor here in the ancestral homestead. I find this process almost unbearably overwhelming. It’s like some kind of impossible Venn diagram. So imagine the following as overlapping circles, please:

“TAKES YOUR INSURANCE”

“AFFILIATED WITH NON-TERRIBLE HOSPITAL”

“RELATIVELY LOW RATES OF CRAPPY STUFF HAPPENING TO THEIR PATIENTS”

“NOT CRAZY: ISN’T GOING TO PLAY DEAD BABY CARD UNNECESSARILY*”

And somewhere in the middle is presumably one person who is not awful. I guess?

This is part of the problem with being a young person in a country that has a stupid healthcare system – I don’t really understand HOW ON EARTH you access medical care. And even now that I have this excellent socialized insurance (suckers!) via Seth, it’s still a mystery. We saw midwives in LA**, and only saw an OB-GYN for one visit to be sure that the baby had a head. And we picked that guy basically because his website was really silly and clearly made by one of his aunts. This is probably not really a good method for picking the doctor who’s supposed to meet you at the hospital in ten short weeks. Right? Right.

AHHHHH SO OVERWHELMING. One wishes it were possible to press a pause button and make everything start up again sometime next year, perhaps after one had taken some kind of class on How To Navigate The Annoying Waters Of Health Care In This Country.

BRIEF NOTES ON CHAIN RESTAURANTS:

Waffle House:

I don’t really understand Waffle House. I’m sorry! It seems like a dingier version of IHOP, only you can’t get fries, they will only serve you mildly depressing hashbrowns. Also (although I noticed this across the more Southern states on our route), the waitresses pretty much cut you off after two cups of coffee. THAT’S ALL YOU GET, LADY, MOVE ON.

Cracker Barrel:

What the eff is this place! They sell rocking chairs by the dozen! You have to walk through a totally bizarre “store” where they sell both chunks of ham and horrible Christmas-themed ceramics to get to the restaurant. The restaurant is dripping with memorabilia of a time that never actually existed – something (I gathered) to do with white people having a good old time in the 1920s raising prize cattle on the farm… and drinking Coca-Cola from glass bottles. Insane farm implements with sharp edges dangle from the walls. I think you could set a wild low-budget horror in one of these places.

Having said all of that, I was kind of impressed by the food. The pancakes were RIDICULOUSLY BUTTERY AND DELICIOUS.

But this waitress, too, cut me off after two cups of coffee.

*shakes fist*

Western Sizzlin:

Dear God, don’t ever eat here! It was THE WORST. Not only was the salad bar made exclusively of gelatinous dressings you had to serve with a ladle and a vat of sweaty baby carrots, it was expensive in that weird way really terrible restaurants sometimes are. Also, our waitress made me feel sad and cringey. She kept coming over to talk to us about how much she wanted to get out of her small town. I was worried we were going to find her in the back of the truck when she left. “TAKE ME WITH YOU, PLEASE I BEG YOU.”

*This is a thing! I am not making it up. Ask some ladies who’ve had babies and some of them will inevitably tell you a tale about how their then-doctor said that if they didn’t induce/get a c-section/eat fewer peanuts THEIR BABY WOULD DIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIE.

**Midwives are super-great because they always think that everything is totally fine. Your bloodwork: fine. Your blood pressure: goes up and down a little bit, but obviously fine. Your weight gain: fine. Your diet: fine. (Even if you have to lie to them a little bit about how many peanuts you’re eating.)

where are they now?

This is a story about sperm. Pray hang in there, Dear Reader — it’s only by way of analogy.

A sperm cell begins life in the testicle. The testicles create about 12 billion sperm a month, which is way, way more than I would have thought. Still, the average human ejaculate contains about 200 million sperm, so presumably our testicles are just trying to be prepared for the average man’s 60 ejaculations per month.

Just kidding, of course. Most of those sperm die inglorious deaths in the testes, never even leaving the curling tubeways of their biological hometowns. Still, let’s say a third or so get to go out into the world. We’ll assume that three-quarters of those actually find their way into the vagina, at least for a little while. But of those, only a very small number will be around on the right day/s — namely, during ovulation. Possibly only one or two ejaculates each month are really in the right place at the right time and get a shot at the grand prize — fertilization.

Still, 200 million is a lot, right? But sperm, it turns out, aren’t very good at figuring out where the egg is. Turns out their strategy is basically just:

  1. Swim around for a while.
  2. Hope to find an egg.

So obviously, right off the bat, at least half the little guys will be swimming in the wrong direction.

The other half go through more tests and trials than Odysseus trying to get back to Penelope. There are simple external factors like gravity, barriers to cross (the cervix, the uterotubal junction), hostile environments (the vagina itself, the uterus), and of course other sperm giving you bogus information about where the egg is hiding. Of course, sometimes the female body swoops down, godlike, and gives a few favored sperm a hand:

Studies in several species have shown that sperm are able to get from the distal uterus to the oviducts in times as short as a few minutes, which is much too fast to be explained by sperm motility. Moreover, dead sperm and inanimate sperm-sized particles are rather efficiently transported upward through the uterine lumen. The conclusion from these types of studies is that sperm transport in the uterus is largely a result of uterine contractions, and that sperm motility plays a minor if any role in the process.

Seriously, how did Joseph Campbell miss out on this? Especially when you consider the complex changes the sperm itself has to go through before it’s ready to fertilize an egg:

Capacitation is associated with removal of adherent seminal plasma proteins, reorganization of plasma membrane lipids and proteins. It also seems to involve an influx of extracellular calcium, increase in cyclic AMP, and decrease in intracellular pH.

Yes, it’s the stuff of myth, all right.

Anyway, only about 200 sperm — yes, literally one in a million — make it to the ovum intact. At this point you would think it would be like the last few rounds of a game of Diplomacy, with everybody turning on everybody else, but in fact during the process of breaking down the thick coating on the outside of the egg, some sperm sacrifice themselves for their (genomic) brothers:

The sperm then reaches the zona pellucida, which is an extra-cellular matrix of glycoproteins. A special complementary molecule on the surface of the sperm head then binds to a ZP2 glycoprotein in the zona pellucida. This binding triggers the acrosome to burst, releasing enzymes that help the sperm get through the zona pellucida.

Some sperm cells consume their acrosome prematurely on the surface of the egg cell, [assisting] other surrounding sperm cells, having on average 50% genome similarity, to penetrate the egg cell. It may be regarded as a mechanism of kin selection.

Or as Jesus would have said, had He been working in reproductive biology, “Greater love hath no sperm than this, that a sperm explode his own head for his friends.”

So it’s a team effort, that last push into the egg, but the fact remains that only one sperm cell’s actual DNA finally gets to merge with the egg’s DNA and make a person. Or, you know, a protoperson. It’s got a lot more hurdles to leap prior to birth. But out of 200 million eager, excited, busy little sperm cells, all of them dreaming the dream, exactly one gets to fulfill its goal. And it’s not by any means the best or most worthy sperm — there may have been tens of millions of sperm cells just as good, just as viable. But they ended up dying in the testicles, or being wasted in masturbation, or swimming the wrong way, or being polite and saying, “Oh, no, you take this uterine contraction — I’ll catch the next one,” or exploding their own heads to help the group. Whatever. Ultimately, getting to fertilize an egg is partly about innate worth, but mostly it’s about pure, dumb, chemical luck.

One out of 200 million. By comparison, trying to become a screenwriter almost makes good statistical sense.


Julie Gray muses here about what the actual ratio of aspiring screenwriters to paid screenwriters might be, but she stops a little short of laying out the full process, soup to nuts. So let’s try it here.

There are 300 million people in America who all think they can write screenplays — minus, I suppose, very small children and a few actuary types who never saw the point in making up stories. Most people will never actually try, of course, in the same way that most people who think they know how to take a guy down in a bar fight will never get around to testing their theories.

But some will. Of those, most will try once, show their script to a few friends, realize that even mediocre screenwriting is harder than it looks, and go back to work on Monday. A smaller subset still will write another script, and another, and another, and another. And of that group, some few thousand of them each year will move to L.A., which is universally acknowledged to be the only way to get to write a mainstream movie, ever, unless you’ve already become famous writing something else.

So now you’re in L.A. You’re in the right place. And so are three million other people. They all want to write, or they want to direct but think they need to be writer-directors to be taken seriously, or they still think, even after trying it a few times, that basically anybody can write. Every actor you meet, for example, has a screenplay he’s been working on for five years — usually inspired by something inspiring that happened to some inspiring person he knows.

Anyway, out of that giant, stewing morass of people who are trying, there’s an elite subset of aspiring writers, at any given moment, whose scripts are being read by People Who Matter. This is the first major barrier for a screenwriter to cross — someone Who Matters has to agree to read your script. If you’re lucky that will be an agent or a manager. (You might think, “Oh, but I’d really like a producer or a powerful executive to read my script, because what if s/he decides to Make It Into A Movie??” But you’d be wrong. No one, no matter how much they love your writing, is going to make your script into a movie. This is also the case if you are a TV writer passing around your spec pilot.)

Now here is the key point — at any given moment, thousands of scripts are being read by People Who Matter, and most of them them will be given a pass, including hundreds of good ones. If you ever thought about applying to Harvard, you may have noticed the little disclaimer in their materials that says, “Each year, we have many more qualified applicants than we can possibly accept.” This is like that.

But suppose you’re one of the lucky ones whose script reaches an agent or manager at just the right moment, when he or she is accepting new clients and is in the mood to tolerate your quirks and can see how your script works in all four quadrants. Now you’re done, right? Your own personal business shark will sell your script to the studios, and then bingo! — wheelbarrows of lucre.

Oh, but you’re so far from the wheelbarrows, and you don’t even know it yet. First your rep works with you on a new script — not the script you just showed him, but something different, something he can sell. So you’ll spend many months writing and re-writing that. Maybe eventually you and your rep part ways, but if not, eventually he may “take out” your shiny new script, a script that you and he have carefully tailored to the current market. And when that script goes out to all the most promising buyers, the end result of all that work is… meetings.

Yes, you go and meet with many, many people. These people are mostly development execs at various levels. Their job is to have meetings with hot new writers and develop relationships, in case their company needs anything written. Of course, the studio that funds their company will have its own ideas about what writers they trust to write a $100 million movie: to wit, there are five of them, and they’ve all written $100 million movies before. But the development execs still need to look like they’re doing something with their time, and so they’re totally willing to meet with you to discuss your “take” on the Korean vampire farce they bought the rights to several years ago. The previous six writers assigned to the project haven’t been able to polish this turd, but why don’t you do some free work on it and see if you really wow us with your fresh insights?

So if you’re going to meetings and being pitched crappy dead projects by development nimrods, you’ve basically made it. You’re in the inner circle. You’ve latched onto the egg, and it’s you and two or three hundred other little wigglers all competing for the same open writing assignment. Which, let’s be realistic, will probably go to David Koepp.

When you write Spider-Man, they give you one of those oversized checks....

When you write Spider-Man, they give you one of those oversized checks....

But let’s say it doesn’t. Let’s say it goes to some profoundly grateful baby’s-ass-new writer. What distinguishes that writer from his or her several hundred peers? Is it some margin of talent? Is it some slightly greater degree of excellence in structure or dialogue or pacing or just dazzling the right people in the right rooms? Is it the extra dollop of sheer, undeniable brilliance that he or she can bring to this particular adaptation of a minor arcade game from 1987? Or is the determining factor just whatever happens to flow through the empty, whistling skull of the congenital retard of the divine family… Luck?

Fortunately, I don’t have to try to answer this question. I’m one of the ones who never made it. Not to say I wasn’t in play — after a few years of mucking around, I moved to L.A. I moved there at the last possible moment, probably, a decade older than most of the other kids kicking around trying to get noticed. But I showed up to play. I moved into a crackerbox apartment in Venice with an aspiring actor and spent eight months writing every night in an internet-free cafe in Santa Monica. I got pretty good, too.

But it didn’t happen. Life intervened instead, and I never had to find out. I’m a full-time dad in less than 11 weeks now, and there’s no more mincing around with half-baked ideas of Chasing Tha Dreem.

Now get a job.

Now find some sort of well-rounded, satisfying professional career, probably in government.

Now dream of reasonable things, like making a difference and someday owning a few acres and half a dozen goats.

Elana’s still in the game, of course. She’s too close not to be. But there’s some kind of weird race between two different drafts of reality going on here — one in which we are still film people, L.A. people, talking and thinking in the language of America’s chaotic, robot-filled dreams… and the other in which all of that recedes into our colorful background as a couple of characters who did some wild stuff before becoming a respectable diplomatic or military family.

We’ve packed up our things, put most of it in storage in L.A. and fled across the country to stay with family until the baby’s born. God only knows what hapens next.

Gooey

You know how “romantic” is the word you want when you’re talking about people who stare at each other, all starry-eyed, and talk about limpid pools? What’s the word you want for ladies who are pregnant and full of warm maternal feelings and who maybe get all misty-eyed when they feel their fetus move around?

WHATEVER THAT WORD IS. It does not describe me.

I did not get excited when I heard the heartbeat.

I did not get excited when I saw the ultrasound (SUCH A LET DOWN! I thought people cried or something. Instead we talked about how giant the Lentil’s skull was. “Look, honey, it has your head!” etc. etc.)

Today we were at the hippie midwives and the lady who wears a turban was all gesturing with the fetal-doppler-heartbeat-finder-thingy and “Seth, come over here and find your baby!” and instead of being charmed I was trying out jokes in my head such as “I can’t believe you lost it again“… etc.

(Health care providers don’t like it when you make this kind of joke. When we went to the OB-GYN, the nurse asked what my husband’s name was, and I said “…Seth.” and gestured to Seth, who was sitting right next to me. “That’s him.” and then I said “Just kidding! He’s just some guy I met in the elevator on the way up.” and the nurse said “…”)

I did get slightly excited recently when doing a craft project involving stenciling animal silhouettes on tiny baby bodysuits… but to be totally honest I think that’s more about how much I like DOING CRAFTS.

The middle section of pregnancy, so far, is fine. The major irksome thing is that I need MANY PILLOWS to be comfortable at night. Sometimes Seth says “Do you… want more pillows?” and I demur politely, and then he says “Do you want one of mine?” and I say “Well… I mean, are you using it?” and then I steal it and add it to the pillow fortress surrounding me. And then sometimes Seth has to say things like “Do you think I could have maybe five more inches of mattress?” and I grumble and move over.

Aside from the house of many pillows, and the fact that I have to pee quite frequently, everything is fine. In fact, it’s SUSPICIOUSLY EASY, this second trimester. I keep thinking that it’s probably a big trick. The first trimester was fairly lame, so if the second trimester is suspiciously easy, I can only imagine that it’s designed to lull you into a false sense of security before the AWFULNESS OF THE LAST FEW MONTHS.

The weirdest thing (aside from the peeing and many pillows) is when the fetus crams him or herself down into a ball in the bottom of your uterus and

a) your stomach gets lopsided and lumpy in this kind of horrifying way
b) then the fetus slowly rolls over or something, and it’s like this totally freaky alien movement that is NOT EVEN SLIGHTLY CUTE. It’s just weird. And it makes me feel slightly queasy.

GOOEY FAIL.

PS, check it out! It’s totally a comic about Seth and the Lentil on a long sea voyage:

marriedtothesea.com
marriedtothesea.com

this could also be the Loch Ness monster

Here’s a story about how our current health care system does not really resemble a free market.

I had never gone to a gynecologist’s office. This is not surprising, but apparently once you become a Dad-To-Be, this is one of the things you do. It’s also one of the things you do at least once when you’re [planning/contemplating/fighting tooth-and-nail over] home birth, because midwives are apparently all “concerned for your child’s health” and want you to “see a doctor at least once.”

How do you find a doctor? This is probably worth a separate post all to itself, but suffice it to say: we don’t know. Normally the midwives recommend that you go to one of the few doctors still ballsy enough to agree to be a backup physician for a home birth. Unfortunately, none of those guys take our insurance. And for complicated reasons, we may not be pursuing a home birth anymore anyway. So Elana went through all the lady-parts doctors in the L.A. area who took our insurance, narrowed them down to the ones who didn’t seem like their primary motive for being OB/GYNs was an academic interest in “Cervical Tumors” or “Abnormal Vaginal Bleeding,” and created a “short list” of possible candidates. Among these, Dr. Arjang Naim had the silliest and most charming website (I encourage you to visit and check out his prom picture!), so we went with him.


So, then — the sequence of events at the doctor’s office:

  • Come inside. Look around. Fill out paperwork while wife goes to bathroom.
  • Hand over insurance card. Try to determine who, exactly, is meant by “The Insured.” Insurance card is photocopied and returned to you.
  • Meet with the nurse, who asks you the same questions that were on the form you filled out earlier. Maybe she’s trying to catch you in a lie.
  • Meet with the doctor. He will be confused about why you only want to see him once.
  • The doctor will ask if you want an ultrasound. Everybody has an ultrasound, and it’s supposed to be a very meaningful experience, so you will say yes.
  • Doc reaches over and picks up a little handheld scanner connected to a crappy black-and-white TV, sticks it on your wife’s belly. Gray blobs grow and contract and vanish and reappear like a particularly dull screensaver. You are underwhelmed. Your wife is underwhelmed. Your baby, meanwhile, apparently has a spine and a normal-sized cranium.
  • The sawbones finishes up his exam and tells you you can leave.
  • You go to the lobby and stand around, waiting for someone to ask you to settle up. No one does.
  • Minutes go by. Other mothers (no dads — apparently not everybody’s dad is a graveyard shift hobo) fill all the chairs, so you stand awkwardly under the TV that runs women’s health ads all day and is currently trying to tell you about the best positions for sex during pregnancy.
  • Your wife, unable to stand it anymore, finally asks the stern Persian lady behind the desk if she validates parking. She doesn’t.
  • You leave. On your way back to the car, you realize you have no idea how much all that just cost.

And this is the glory of our non-capitalist, non-socialist system, in which all decisions about care are made in a financial vacuum. We don’t know, even now, how much that visit cost, how much our insurer was charged, what size bill we can expect to receive, whether the worthless ultrasound cost extra or was included in the bill. We also don’t know, given that it’s August and that we have a $300-per-financial-year deductible, whether we would have gotten a better deal if we had just not bothered giving them our insurance card and instead negotiated a flat out-of-pocket fee.

No one gives you a bill when you leave the office, which I suppose is okay, since no one asks you for money, either. It’s taboo to talk about money in a doctor’s office, I suppose, which is strange for the kind of place that has a billing department. I mean, I understand the social awkwardness about money when it comes to certain sacred professions. My college called my student loans “financial aid” and liked to act like the quad was basically a philosopher’s grove where any curious traveler could seek enlightenment. But they still had an office with windows and teller drawers and accountants who would tell you how much you owed.

There’s something very strange about this for what is supposed to be a capitalist transaction. I mean, imagine if other stuff worked like this. You go to the supermarket, and there are no prices anywhere. And then at the end you just walk out.

“Do we have to pay for this?”

“Oh, we’ll bill your fruit insurance company, and they’ll send you a statement.”


So, in case it ends up costing us $60,000 and an act of prostitution, here’s a printout from that ultrasound. It apparently indicates that we’re going to be raising a blotchy gray triangle.

Lentil's first photographic invasion of privacy -- there will be many more!

Lentil's first photographic invasion of privacy -- there will be many more!