Monday, October 28, 2013

Alternate life me

One thing that's kind of unusual about our wonky infertility journey is its start. Based on the spouse's health history we figured it would be hard to have a baby of our own. I don't think most people start from the premise that getting knocked up isn't so simple as it's made out to be in the media.

So we set out figuring a year trying was to be expected. Or at least six months. Then the spouse would be done with grad school and have a job and I'd be in semester 3 of 5 before that science teacher license was finished. 

Of course that crashed and burned and the fiasco that ensued was just astounding. 

But I've been thinking about Alternate Life Me who got up for that 8am chem class I dropped. Let me take a moment to point out the awful advising I got. I came in wanting to take music theory, French, and chemistry as possible majors. The person advising me first pointed out that the chem class met 5 days a week at 8am and "are you really sure that's what you want to do?"

And I went to a women's college.

I got advised only on the negative side of that chem class, not that it was a prereq for any health or science grad work, not that the 8am time was to weed out nursing majors who didn't mean it, not that if I was thinking about a science major I had to take it or gain a full year of college (the bio major sequence fit into 3 years but needed that chem class as a prereq too). I wish I knew what random prof I had as my advisor that day so I could send her an angry note. Even though I was considering 3 majors, French, music, and chemistry, the chem class was the one I was advised out of rather than the music class that was within a dying major (the last music major graduated with my class).

Anyway, I got influenced by a bad system that didn't advise me strongly into a science/tech field despite my interest.

Alternate life me, who took that 8am class, probably would have majored in chemistry because it's FUN. Perhaps not to people who aren't me or even most people, but I love it. Maybe alternate life me would have figured out the whole calling to be a pharmacist deal a bit sooner than 6 months post-graduation, but maybe not. Even if it had been that 6 months post-graduation revelation, I could have applied to start the next year with a spanking new chemistry degree. Alternate life me would have 3 or 4 years less of college. That's a lot of time I won't be working, or that I'll be working instead of retiring. Sigh.

 Of course, especially when the 5 year old is being a tornado of repressed-until-bedtime emotions at night and waking up for the day at 5:15am (seriously UGH), I think about what alternate life me would have decided about children. Knowing  what we did before we decided to try for a baby, would having a firmer grasp on school or another major so there was no giant life shift have changed what we decided, that trying young was important because we might not have much luck?

One of my high school classmates got that undergrad chemistry degree, went right to pharmacy school, did a residency, got the perfect job, and then bought a house and had a baby. Everything in the right order. Sometimes I worry that putting life in all kinds of a jumbled order has been detrimental. It would be a boatload easier to study with no screaming 5 year old stressed because she got confused and didn't get her after school snack at the program she goes to (and professes to hate after she claims she had fun right after the thing ends). We are surely much more broke because there are two girls hanging around, and we are also stuck here where the spouse's job prospects are now limited sharply. The benefit is that we can just move for my job when it exists, but that's sort of a lot of pressure to put on my fledgling career.

I wonder about all the folks around me who are delaying having children right now and if it enters their minds that children don't just turn up 9 months after you start trying. I know a friend with PCOS certainly does think about it but I'm not sure if it's good or bad that so many folks don't even consider the possibility of infertility or loss. On the one hand it is so much harder going through infertility when nobody has any idea how to react and everyone has helpful un-advice like Just Relax! On the other hand, it's kind of nice not to have everyone so knowledgeable that they keep asking about what's going on all the time. Sometimes it is nice that what you're going through isn't common knowledge. It provides at least a little privacy if you want or need it.

My high school class is having a get-together coming up soon and I'm excited or terrified. I think I'm still the only one with kids I'm parenting (one person had a baby placed for adoption not long after graduation, and yes, tiny high school...) so that's weird. I bet this time there will be less "oh how weird you have kids" and more "so how's that going? We're thinking about kids now too" than there was about 5 years ago when we got together last (maybe it wasn't that long ago but I don't remember clearly). Upside: I'm not the only person still in school! One of my classmates worked her way through community college in 6ish years and then finished a bachelor's degree in the next 2 and is working on an advanced degree now (unsure if it's just master's or masters to PhD). It mostly makes me feel old. Is this the end? The last baby? The last time I'm "young" or anything like it? Is alternate life me happier or more miserable stuck in infertility purgatory longer? I suppose it's better not to know. I do know that today is pretty all right.

Monday, October 21, 2013

Feeding the baby part 3: travelog

Continued from parts 1 and 2, here is pumping part 3: oh man I dislike pumping

I was out of town for a week (all alone) so I got to manage pumping and being away from the baby and then transport back of all the milk. Here's how it worked out.

First I attempted to replace my crappy pump that seems to be dwindling in ability to function. Due to some insurance mumbo jumbo gone wrong the pump arrived Monday when I left Saturday and since I was in a rural area with no UPS, there was no shipping me the replacement. I think the problem may be that I need to replace my squishy parts but this didn't dawn on me until it was too late to get the parts.

I attempted to pump 4 times a day while I was away but actually I hit only 3 times a day each day. It seems to have worked out all right. My supply isn't back up to pre-baby-free time levels after 3 days of nursing lots but it seems to be adequate enough for her tastes. It also helps that this week was one where her solid intake cranked up like crazy so there are many demands for more solids from Little Monster. For comparison, she had been nursing 5 minutes at a maximum and with lots of choking and howling breaks before and now she's nursing more like 7 minutes with some breaks to look around and be distracted. The choking is gone and that's great from my perspective. She's also eating about the same number of times a day as before just with that little bit longer duration.

As far as storage and transport goes, this took some consideration. I brought 2 sets of pumping flanges,1 pair of 9 oz bottles, 1 pair of 5 oz bottles, and a box of 50 milk bags along with. I flew (a couple hour flight I think? Time zones always throw me off) and then drove another 5 hours out to the week's location. Because of cost I needed to have no checked luggage going out so I could afford to check one bag coming back and have the cooler as my other carry-on. I packed a soft-sided cooler in my suitcase's laptop pocket (this one) and bought a couple of ice packs on arrival because it was about 14 hours minimum from departure to getting home and the cooler was rated for about 10 hours' cold time with no ice. I also selected a soft-sided cooler because it was light. Hauling a bunch of milk around isn't light and I didn't want to add a couple pounds of cooler if I didn't need it. I brought home about 100 oz of milk in 5-6 oz portioned bags plus one bottle from the morning I left. It actually took us more like 18 hours to get home from the time the milk left the fridge. It was all still pretty close to fridge temp coming out of the cooler so I highly recommend that cooler (no, it isn't an affiliate link or anything and I paid for my cooler but I love it). It was large enough that my pump flanges and cover went in the bag with the milk as I was low on space, yet it was small enough to easily fit under the plane seat. The handle was really comfy for hauling it around airports too which was a great thing. I'm using this cooler for any future tailgating!

The bags were kept in the fridge during the week because fresh milk can tolerate temperature variations while frozen stuff is no good if it thaws, and because my host had very little freezer space. They got deep frozen this morning because that's when I realized I'd better do it so the oldest milk is at the high end on storage at about 9 days but is likely to be fine. I'm not opening it to check its freshness though!

The most annoying thing was to shadow in the hospital, hear that they like to support moms nursing, and then discover that the hospital doesn't rent or sell electric pumps, only single hand pumps and you have to see a doctor to get one. Um, what? I mean it is an area where not everyone has a fridge at home but for all the moms who work (most of them at that hospital) how discouraging to have to drive 3 hours to buy a pump or have one mailed and have much the same fiasco with mail order that I did, plus the extra time to use the post office. UGH. They also don't have a lactation consultant on staff either. Support? Hmm... maybe not so much.

It was also pretty funny how uncomfortable the whole thing made my female professor who was in charge of our trip. She didn't even want to say the word "pump" out loud. Hah. Having now nursed two babies for a total of 21 months, nothing phases me. On the way out after we left the airport I pumped in the car with my fellow students arguing about the radio station the entire half hour. No big deal. Big thanks to Josie for lending me a nursing cover so I could pump wherever. I am awful at using a cover and am thrilled I probably won't have to do it again (maybe ever).

Now I'm off to clean the new pump parts so I can try the thing out. Maybe. Or maybe I'll just use the new collection kit with the old pump.

Thursday, October 10, 2013

Schroedinger's baby

Gah things are wild around here lately. Just wild. Our faith community has this deal that we are supposed to spend 5 minutes a day doing faith stuff together and we just aren't able to manage that. Too many temper tantrums and emotions saved up to exploding at bedtime for us to manage 5 quiet minutes together... My personal favorite thing from the last week was trying to explain my sentence "Spouse has to jump through hoops right now so we can keep getting unemployment money since Spouse's job is only part time" to my 5 year old. It took 10 minutes and I don't think it really clicked with her, since she's never seen a dog doing tricks, barely ever seen a hula hoop, and has a very limited concept of money at all.

Anyway, I thought I'd talk about this interesting/strange thing that's helping me cope lately. I hear a lot from folks who are parents of babies (experience with baby/pregnancy loss or not) that they worry about if baby is still alive and breathing while asleep. I worried about it a lot too. Then one day I didn't any more.

This thing occurred to me and I have found it helps me sleep better. I just have decided that Little Monster in her crib asleep is Schroedinger's baby. She could be asleep, awake, or dead. If I go check, the odds go up very much that she will be awake since I smell like food. If I don't go check, I have to accept that I don't know. I've concluded though that (very morbidly) if she's dead now, she'll still be dead in the morning and if I've slept I'm much more likely to be able to cope so why rush the inevitable by checking on her now?

Probably having accepted sleeping Schroedinger's baby is healthy or weird or I have no idea what actually, but it is working. We don't have a monitor and we are clearly not getting one since her bed is within 10 feet of ours (in the next room).

And now Schroedinger's baby is howling awake. AWAKE and must be attended to.

Tuesday, October 1, 2013

Health systems

Caution: I am liable to rant because I am just fed up with healthcare lately. UGH.

So today the US government shut down because one party is grumpy that the Affordable Care Act is going to happen and be implemented. Today is the day to start shopping for healthcare plans if you are in healthcare limbo and to sign up if you are eligible for subsidies to help pay for healthcare! I hear the website is a wee bit slow, probably because a whole lot of people are excited at the prospect of healthcare. I sure am. Here's the website where you can check out your options and find your state's insurance exchange (if it has one).

It confuses me to no end why 20 years after the Republicans proposed exactly this healthcare reform it suddenly makes them super mad and in a mood to object to every little thing it might change even though most people support the changes it will make. The bulk of the changes are nice things like affordable insurance for a great many people, children can stay on their parents' insurance plans a long time, and pre-existing conditions as a reason to deny health insurance are gone. That doesn't mention all the preventative healthcare services that are free and designed to reduce costs in the long term like free annual wellness exams, free shots to prevent diseases, and free contraceptives to prevent pregnancies or acne.

But health systems. ACA also includes some money for healthcare providers to get themselves together IT-wise and it would be amazing if it included money for meaningful use by pharmacists and pharmacies, but no. In case you were curious, doctor's offices pay nothing to send electronic prescriptions but pharmacies pay to be in the network to receive them. It obviously takes a computer system to do that receiving. I've been to a pharmacy that uses a DOS-based system, now, and it receives electronic prescriptions, which is awesome on the one hand (legacy system for the win!) and depressing on the other (I used that system on our home computer back a zillion years ago before I started kindergarten!). It's a shame there's no money from the government for pharmacies to upgrade their IT systems.

ACA also encourages the formation of new things called accountable care oganizations (ACOs) and a switch from a fee-for-service model to a patient wellness payment model. That amounts to encouraging groups of providers to work together to get and keep patients well rather than for each one to bill the patient for every little test they can manage to make the most money. Pharmacists turn out to be a really key part of making ACOs work (at least that's what the pioneer ACOs are finding and the data supports it, squee!) and yet we don't have status to bill as a healthcare provider. Another complaint of mine. Soon though, maybe pharmacists will count as real healthcare providers for billing purposes so we can get paid for our work getting patients to take their medications and to take the right combination to help keep them as healthy as possible.

BUT. This "providers work together" thing has gone various degrees of well for different newborn health systems. In my region there are a few big ones, markedly different ones at that. Where we used to live we had a real health system. Here we have a bunch of providers with a matching logo that actually have next to nothing to do with each other.

Let's use an example. In system A, where we used to live, patient Z needs to see a specialist for a foot problem (that's a podiatrist). Patient Z stops at the appointments desk after the visit with the primary doc who said the specialist was needed to make the appointment. The podiatrist works for the system and is only in Little Town one day a month, so Z needs to schedule to see the podiatrist in another location. This is no problem and the appointment scheduling person either looks up the full schedule of various locations using the computer or calls another location to do the scheduling right then. Obviously, because this is a health system, the appointment scheduling person has the appropriate number to call any other location within the health system to make sure the appointment gets scheduled seamlessly within minutes. The entirety of Z's electronic medical record will travel easily to the podiatrist at any location within the health system where Z might be seen and any reports/test results/notes made by the podiatrist will be easily accessible to Z's primary doctor in return.

In system B, where we live now, when Patient Z needs to see that specialist who is at the local location one day a month, if that day doesn't work, next month is an option. Z probably didn't see a primary care provider because the Big Awesome Hospital in the area recruits new hires to the outlying clinics and then promotes them to work at BAH without filling the vacancies. BAH probably set up the health system as a way to vet new hires and not as a way to make healthcare more accessible to folks in the surrounding area. Patient Z cannot find out when the podiatrist will be at any other health system locations from the scheduling assistant in Little Town because the department doesn't keep track of things like that! The scheduling assistant certainly can't get Z the number to call BAH and try to schedule a visit in the city because why would the department have that number? Health information needs a form to be shared between BAH and Little Town clinic despite them being under the same logo and presumably part of the same health system, and even when the form gets filled out, Little Town will call just to make sure it's really necessary to send all the records (which are paper and electronic in some very dangerous hybrid). It is unlikely that information will come back to any primary care provider from BAH either, not in a timely manner.

Two ways a health system is set up, one that is patient and provider friendly, one that is not. I get that joining a health system is a new thing for clinics and hospitals that operated in isolation before but refusing the transition because it's scary and new is a mistake. New things in healthcare are hard of course, but systems are the thing of the future. Even if on the business end of things the providers stay separate, sharing patient information electronically is the thing we'll be doing soon. I'm not sure how my state's health information exchange is currently going but I think it will exist sometime soon. Lives get saved by sharing information. Lives get saved when I can query the health information exchange in the ER and find out someone is allergic to penicillin before we give a dose even though they are unconscious. Lives get saved when we find out someone carries MRSA when they arrive in the ER so we can isolate them and help prevent its spread.

Health systems help patients get better care by facilitating data exchange. It tempts me pretty often to drive a couple hours to see a provider in our previous system just to avoid the headache of the dual paper/electronic chart and the wrestling match it takes to get a timely appointment to see a specialist for anything. The part that really bothers me is that it's so hard for me, someone who knows an awful lot about how healthcare works and how it should and can work. It took me hours to get in to see a specialist. How many people who are actually sick (I'm just getting continuing care, it's boring really) give up or get confused and quit bothering to try to get appointments they need? Why are we growing health systems that don't work like a system to help patients manage it all? It's important to focus on what we do when health systems grow and to make sure we fill primary care positions (and that's another issue entirely) and to make sure training is even across the system so things work like it's a system and not a bunch of discombobulated locations with a matching logo. Electronic health records really help that information sharing happen seamlessly (we hope) and it's high time to embrace them. Health systems need to grow because the payment model is shifting to ACOs, maybe not to gigantic proportions like Kaiser in California/the western US, but also pharmacists need to get in on building ACOs so patients get good care from the moment they walk in the door to the moment they head home with any new prescriptions from the pharmacy.