Early in his career, one my colleagues remembers greeting with mother-in-law with the standard, Hello, how are doing," expecting a return, fine, and how are you?
Instead, she replied, "the floodgates have opened," leaving him a little confused. He later realized--perhaps with the help of his wife, that she was referring to the onset of a heavy period.
Like most phenomenon, menses follows a bell curve. So though most women may describe a 4-5 day flow, a small group may experience 2 days of light bleeding, and an equal group on the other end of the curve may have 7 days of heavy flow, enough sometimes to keep them home for a day or so.
Lindsay has been bleeding for three weeks, never like this before and with no apparent reason. She has lost about half of her blood supply. As a healthy 23 year old, she is able to tolerate this loss to a degree. She can walk around but has a strong headache and could not deal with her job where she stands most of the day
If the bleeding stops and she tolerates iron supplements, her level could be back to normal within a couple of weeks. But she has been offered a blood transfusion because another few days of heavy bleeding could lead to a life-threatening level. That would allow her to return to work. A temp worker now, she wants a full-time position and is worried that taking time off now (which she would have to do for a several days if she does not received a transfusion) would jeopardize this advancement. She says yes to a transfusion.
So we stopped the bleeding with intravenous estrogen and gave her two units pints of blood. The average adult has 10-12 pints of blood, so while two units will not put her pack to normal, it will take her out of the danger zone.
Cathy has been pregnant nine times: one child and 7 abortions. Today she is in tears because she is pregnant again and an early ultrasound showed a small fibroid which she misinterpreted as meaning an inevitable miscarriage. She really wants a second child.
At 19, Ericka did not plan this pregnancy with her live-in, unemployed boyfriend, but she says she is okay with it. At least until she became ill at six weeks (just a month after conception), with nausea, vomiting, diarrhea, and abdominal pain. A little early for morning sickness, perhaps just a prolonged viral gastroenteritis ("stomach flu"). Or a combination of the two.
I met her for the first time this morning, her 4th day in the hospital. Talking with a couple of the nurses, it appears that she has not had any visitors during these four days. With a couple of intravenous anti-emetics (she refuses to take pills), she was able to eat for the first time this morning. She wanted a burrito but a nurse limited her to some applesauce and similar soft foods. A few hours later, she was throwing up again.
I need to talk with her, but she hides her face in the pillow and complains about the light when I open the door to her room. I don't want to talk, she says, I just want to sleep. I tell her that I need to have a serious discussion about other treatments. Because she talks so softly, I bend on my knees (no chair available) to get close enough to hear her responses.
"You're creepy, staring at me like that."
Accepting my dismissal, I told her I'd be back in a few hours when she might be feeling better. As I left I could hear dry heaving in the background.
Usually when we consider the non-insured, the non- or under-employed come to mind. But not always.
At 37, Trish and her husband have no insurance for delivery and only high-deductable for non-pregnancy care. She is an attorney and her husband a family practice doctor. If they were employed by a large system, say a hospital or a large legal firm, they'd have insurance, but as solo providers, they have opted for a high-deductable individual plan.
Anything else would be very expensive even for this double-employed couple. Remember that not all lawyers are millionaires and family doctors are at the low end of doctors income scales.
"She is very concerned about the cost of everything," notes the midwife she sees, explaining why she is having blood drawn at her husband's office. She will not ask for extra (but not necessarily indicated) ultrasounds and she's hoping for a less expensie vaginal delivery (first child was cesarean).
We feel uncomfortable with patients or doctors making decisions based on financial reasons, but maybe that's the only way to control medical costs.
Lindsay has been bleeding for three weeks, never like this before and with no apparent reason. She has lost about half of her blood supply. As a healthy 23 year old, she is able to tolerate this loss to a degree. She can walk around but has a strong headache and could not deal with her job where she stands most of the day
