Category Archives: Reflections

Taking the Wrong Way Home

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A pregnancy starts when a Fallopian tube sweeps up an egg like a shop vac and sends it down towards an army of sperm lying in wait.  While it takes one sperm to fertilize an egg, it takes hundreds of them to break down the zona pellucida, the egg’s barrier to fertilization.

When that happens, the lucky bastard yells, “I’ve got you now, my pretty,” and thrusts himself into her.  Now joined in holy matrimony, the fertilized egg – a zygote – takes a short honeymoon trek down the tube, developing into a blastocyst on its way the uterus. There it implants, sets up housekeeping and watches Netflix for the next nine months.

But that doesn’t always work that way. The blastocyst may attach itself somewhere outside the uterus in an “ectopic” location that wasn’t designed to grow a full-term baby. Those sites include the Fallopian tube (the most common); the cornua (where the tube attaches to the uterus); the cervix; an ovary or inside the abdomen.

An ectopically implanted pregnancy is more likely in a woman whose tubes have been damaged by infection, endometriosis, or previous abdominal surgery, including tubal ligation.  Using an IUD for contraception increases a woman’s risk. Even a woman who has had a hysterectomy but with an intact ovary can become pregnant, likely earning her a place in the tabloids.

An abnormally implanted pregnancy can only grow so much before the tissue around the implantation site blows apart and all hell breaks loose. Internal bleeding can be massive and a woman will die from hemorrhagic shock if not treated promptly.

The Arab Spanish physician Abulcasis (Arabic name: Abul Qasim Khalaf ibn al-Abbas al-Zahrawi al-Ansari), was an impressive and accomplished dude who wrote Al Tasrif, a thirty volume medical encyclopedia, earning him a place among the “fathers of surgery.” He made the first known reference to ectopic pregnancy in the 10th century. Other physicians reported ectopic pregnancies during the next 900 years, largely discovered at autopsy as it was invariable fatal.

But by the mid 1800’s doctors were becoming more aware of the signs and symptoms of ectopic pregnancy. Timely surgical intervention saved the lives of many women but definitively differentiating an ectopic pregnancy from other conditions – an ovarian cyst, endometriosis, or appendicitis – remained problematic for the next 100+ years.

Such was the state of diagnostic abilities when I started my residency in 1979. A woman who came to the Emergency Room in obvious hemorrhagic shock – high pulse and low blood pressure – went straight to surgery. But if she presented with lower abdominal pain, a positive pregnancy test and sometimes brown vaginal bleeding – and was hemodynamically stable – we tried our best to confirm an ectopic pregnancy. The probability increased if, on pelvic examination, one felt a painful mass on either side of a normal-sized uterus, but there was still a 20% chance it was something else.

Ultrasound had been used clinically since the mid-1950s, but images weren’t great, appearing more like abstract paintings than pelvic organs. Radiologists’ interpretations were often ambiguous and usually unreliable when proclaimed with absolute certainty. One of my attending physicians opened up a woman’s abdomen after the radiologist said, “There is definitely an ectopic pregnancy here,” only to find absolutely nothing.

If we were still unsure and the woman agreed to it, we’d try doing a culdocentesis.  That involved sticking an 18-gauge needle through the back of the vagina below the cervix, then pulling back on the plunger of a large syringe. (Yes, it’s as painful as it sounds, even after injecting local anesthetic into the area.) Sometimes we were lucky. If the syringe filled with “non-clotting” blood (blood that had already clotted and then broken down), we knew she was bleeding internally and likely had a ruptured ectopic pregnancy. If culdocentesis wasn’t successful and we still weren’t sure, we took the woman to the operating room for diagnostic laparoscopy sparing the woman an abdominal incision if everything looked clean.

Tubal pregnancies are usually dark purple blobs, ranging in size from a pomegranate seed to a breakfast sausage, which may be leaking a little blood or actively hemorrhaging. There’s usually a small piece of placental tissue among the clot in the tube, but nothing that remotely resembles a fetus. I witnessed one notable exception during my residency. A tiny, live fetus, about the size of a grain of rice, was moving in the small gestational sac that had been expelled from the end of the tube. And no, there was – and still – no way to implant it into the uterus! Placental tissue, once disrupted, won’t reattach itself in the uterus.

We had three surgical options:

  • Opening the tube over the affected area, emptying out the contents and delicately sewing the incision shut, making sure there was no bleeding. The tissue was fragile and it was like sewing two sticks of room temperature butter together.
  • Taking out the damaged section of tube, leaving the ends for a skilled microsurgeon to put back together later on.
  • Taking out the entire tube because a badly-damaged tube made another ectopic pregnancy more likely.

A lot has changed since I started residency more than forty years ago.

Diagnostic testing

Simple urine or blood pregnancy tests, first developed in 1976 and referred to as “qualitative”, look for the presence or absence of human chorionic gonadotropin (hCG) a hormone produced by placental tissue.  A positive test indicates a pregnancy somewhere in a woman’s body. A negative test usually means there is no pregnancy but the test will be “falsely negative” if hormone levels are too low to detect.

Structurally, hCG is made up of two pieces: the alpha subunit (α-hCG) which is also common to ovarian and thyroid hormones, and the unique beta subunit (β-hCG). Starting in the early 1980s, laboratories were able to assay blood for small amounts of this beta unit, the “quantitative β-hCG test.” We used the changes in hormone level over several days to monitor very early pregnancy development, hoping to distinguish normal pregnancies (single and multiple) from abnormal ones (blighted ovum, miscarriage, ectopic, the varied forms of molar pregnancy, or placental fragments leftover in the uterus after a miscarriage).

Measured in milli-International Units per milliliter (mIU/mL), hCG becomes detectable around the third week after a missed menstrual period. hCG levels should double every 48 hours in a normal pregnancy and transvaginal ultrasound should be able detect a gestational sac in the uterus at around 1,500-2,000 mIU/mL. One can reliably rule out an ectopic pregnancy after detecting a fetal pole (the earliest evidence of a developing embryo) with a heartbeat. (Simultaneous intrauterine and ectopic pregnancies occur spontaneously in less than 1:30,000 naturally occurring pregnancies, but that incidence increases to 1:100 to 1:500 with in vitro fertilization.)

hCG levels that rise more slowly, plateau or decline usually indicate an abnormal pregnancy. Combined with serial ultrasound examinations will lead to diagnosing:

  • A blighted ovum if there is an empty gestational sac with no fetal pole;
  • An inevitable miscarriage if there is a fetal pole larger than 7mm with no heartbeat
  • A miscarriage or ectopic pregnancy if there is only placental tissue in the uterus at levels where we would expect to see a gestational sac.

If physicians can’t rule out an ectopic pregnancy, they’ll scrape tissue out of the uterus (a D&C) and ask the hospital pathology department to look at the tissue while still in the operating room. If there’s only endometrial tissue and no chorionic villi, the vascular bridge between the uterus and placenta, there’s an ectopic lurking somewhere.

Imaging

Ultrasound image resolution has progressed from vague static images like this:

 to detailed, real-time images such as this fetus (the four lines in the black area is the umbilical cord).

Color flow Doppler ultrasound can show blood moving in and out of an ectopic pregnancy in the adnexa, the area next to the uterus, which is helpful if the sonographer can’t distinguish a definite mass. (This, however, is Doppler flow of a heart, the only royalty-free image I could find.)

So, when a radiologist tells me, “There’s a 2cm mass with blood flow in the right adnexa, nothing but endometrial tissue in the uterus and a lot of echogenic material in the cul-de-sac running up the para-colic gutter,” I know I can skip the laparoscopy and open her up.

Surgical treatment

However, surgical treatment has also changed. Tubal ligation was the only surgical procedure we did in the early 1980s. By the early 1990s, physicians with far more balls than me, along with surgical instrument innovations, were starting to take things out of people laparoscopically. Removing an inflamed appendix became a simple outpatient procedure. Taking out a gallbladder full of stones using a laparoscope was far easier and less traumatic than the old days which required an incision along the right rib cage from stem to stern, and digging deep while your poor intern (me) tried to retract a six-inch deep wall of fat with a “Weinberg Vagotomy Retractor,” otherwise known as Joe’s Hoe (and it is as big as the garden tool).

“Pull harder, dammit!”
“I’m pulling as hard as I can!”

Operative laparoscopic surgery had a steep learning curve in the early days and I was skeptical of the newfangled approach to ectopic pregnancy. I was suckered into assisting two youngsters with far more confidence than ability and both endeavors lasted two hours. One insisted in putting a trocar (which looks like a tent stake) through the abdomen in the vicinity of the inferior epigastric artery, despite my pleas to reconsider. She wasn’t concerned with the pulsating stream of blood and continued prospecting for the ectopic pregnancy.

I got a call one Saturday at midnight from the ER doc at a small hospital in Nebraska, 70 miles away from where I was working.

“I have a woman here with a ruptured ectopic pregnancy and I want to transfer her.”
“You don’t have anyone there who can deal with it?”
“Well, the general surgeon comes here on Wednesdays but I don’t think she’ll hold out until then. I’ve started a unit of blood and the ambulance is here.”

I was working as a locum tenens in someone else’s practice. I called the senior partner since he was rather protective of the practice’s reputation and I didn’t want to step on any toes. He wasn’t happy but met me in the Emergency Room. The woman arrived about 1:30am and, after introductions, examination and discussion, we were in the operating room at about 2:00am.

Setting up for an operative laparoscopy takes at least half an hour or more after the patient goes to sleep. The equipment includes:

  • a video camera and two monitors
  • the laparoscope light source
  • the CO2 insufflator used to blow up the abdomen like a balloon so the surgeon has room to work
  • an electrocautery unit
  • reusable instruments like the laparoscope and the insufflation needle
  • an array of expensive, disposable stuff like operating ports, instruments to cauterize vascular pedicles, a combination irrigation/suction device hooked up to room suction and a bag of saline,
  • and a uterine manipulator, which requires putting the woman in stirrups, putting on the surgical drapes, using a speculum to find and dilate the cervix before inserting it into the uterine cavity.

Laparoscopic surgery starts with putting in the insufflating needle just inside the belly button, the thinnest part of the abdominal wall, then filling the abdomen with enough CO2 so there’s room enough to work. After that, the surgeon inserts at least three or four ports in the abdomen: a 10mm for the laparoscope; a 5mm just above the pubic bone for a wand to move the innards around; and 5mm or 7.5mm ports on either side for operating instruments and grasping. (I have six abdominal scars from my robotic prostatectomy.)  Click here for a great overview of laparoscopic trocar placement.

Older ports consisted of a stainless steel trocar with a pyramidal end like a tent stake inside a stainless steel sleeve which one pushed this through small incisions, taking care not to puncture the bowel, the bladder or the aorta. Newer ports are disposable plastic with more blunt trocars to minimize the chance of damage, but they take a little longer to work through the abdominal wall.

So, after setting up, gently and deliberately excising the damaged portion of tube, sucking out blood and clot, irrigating the pelvis, inspecting to make sure everything is clean and hemostatic, taking all the instruments out and closing the incisions, we were done about 90 minutes later.

My approach to an ectopic pregnancy in the good old days was direct. I’d make a small abdominal incision, grab the tube with a Babcock clamp, remove the offending ectopic, clean out the blood and clots in the pelvis, inspect the other tube and ovary, and then close her up in 20-30 minutes.

It’s one of many reasons I’m happy to pass the baton to a younger generation.

Medical Treatment

Methotrexate, a drug initially used to treat cancer and then rheumatoid arthritis, is sometimes used to treat unruptured ectopic pregnancy. There are stringent criteria for its use – a stable and reliable patient, a mass less than 3.5cm, hCG < 5,000 mIU/ml, and no detectable cardiac activity – and the woman must be monitored closely with serial hCG levels. Success rates are reported to be around 90% when used appropriately.

The emergency room physician at a small hospital in Tennessee called me around 11:30 pm on a Sunday night. A 42-year-old woman came in complaining of vaginal bleeding for a week and severe pain in her right lower abdomen.  “She has a positive pregnancy test; her hemoglobin is 8 and her pulse is about 110.”  A normal hemoglobin level for a non-pregnant woman is 12-16 gm/dl; even in pregnancy the level should be 11 or so.

I walked into the examination room and met a slightly pale woman on a gurney; her husband stood next to her.

“Hi I’m Dr. Rivera. I assume the ER doc has told you why I’m here?”
“Yes, he told me I’m going to need surgery.”
“Well, that’s a good place to start. Tell me what’s been going on.”
“I started bleeding off and on last Monday. I didn’t think much of it, but it hasn’t stopped, and I started having pain in my side tonight, so I came here.”
“Have you felt any pain in your shoulders?”
“Yes, my right shoulder started hurting two days ago.”
She noticed the look on my face and asked, “That’s not good, is it?”
 “Not really. If you’ve had internal bleeding the blood can irritate your diaphragm and your body interprets that as shoulder pain.”
“Yes, but how can I be pregnant? I had my tubes tied thirteen years ago!”
“Well, tubal ligations have an inherent failure rate. I saw one woman who got pregnant after her tubal. I took out her tubes after delivery and found an inch gap in both tubes.”
“Really!”

So I took her to the operating room. My scrub tech was the Czechoslovakian grandmother who always made sure I was well-fed when I made rounds in the morning. I was sure I didn’t need to start with a diagnostic laparoscopy and went straight to an abdominal incision. She had 1300cc of blood and clot in her abdomen from a ruptured ectopic; I took out what was left of both Fallopian tubes. By now she should be menopausal and safe from that sort of misadventure.

For all the progress we’ve made, some want to turn back the clock. Some Right-to-Life types have conflated treating an ectopic pregnancy with abortion, saying intervention isn’t necessary. The author of that article has since apologized, but the damage has already been done and such misinformation has already spread.

Graphics © Can Stock Photo
Explosion: Jag_cz
Fertilization: stockdevil
Ectopic Sites: normaals
Ectopic: Kateryna_Kon
Fetal Sonogram: faustasyan
Doppler: faustasyan

The More Things Change

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December 13, 1977
My few days at the abortion clinic. The doctor is an OB/GYN who has also been doing abortions for 5 years. The office is attractive and comfortable. No one has ever been turned away for financial reasons. They will do abortions up to 14 weeks; after that they will refer the woman to someone who will do it later than that.

My first day; the receptionist gets a call at 8:30am. “Yes, Ma’am, I’m glad your mother did not have an abortion and I’m glad my mother didn’t either…No, we are not influenced by Communists. We don’t want to have anything to do with Communists…No, anyone who gets an abortion wants one. We don’t force people to have them.”

Every woman is personally counselled before the procedure. The woman is informed of the alternatives (having it and keeping it or giving it up for adoption, or having the abortion). The woman is asked why she wants it and is asked to sign a consent form. The procedure is explained in detail: the lab work (blood pressure, HCT (hematocrit); Rh typing and urinalysis); the actual abortion and the post session.

The woman is told what may happen as far as cramping: what to watch for; who to call if she has any questions. (Don’t go to the local Catholic hospital emergency room; women who have get pretty bad treatment.)

The first woman I go through with is young (about 20), unmarried, with her father. She is cool, a little afraid but very realistic. Everything goes OK with no problems. We talk before and after. She wants an apartment and is ready to leave home. Her father is surprisingly calm and is glad it isn’t “like the butcher shop years ago, f’ Chrissake!” We talk about Rhogam (she is Rh-negative), other methods of birth control, and so on.

The women are of all ages: young, middle aged, married with kids, single, divorced. Rich, middle class and poor. The reasons: “I’m not ready to start a family.” “I have kids and I’m getting too old.” “I can’t take being pregnant again.”  How they got pregnant also varies: rhythm that didn’t work; a busted rubber; foam and no rubber; forgot the diaphragm; just got careless.

Some want to have kids later and feel it is the wrong time to start families. Some are from small towns, some from the big city. Catholic, Protestant, other.

Many of them are resentful of the Illinois legislature. Some think the representatives (mostly men) ought to try being pregnant. Most feel the option ought to be available. Everyone is glad to get it over with and swear they will never take chances again.

One woman today expressed frustration and anger at her husband, and at men in general who think birth control is always the woman’s responsibility. I’ve heard the reasons she says her husband gives and can’t believe people are still really like that. I feel for her because she is in a rotten position and needs some support. I listen and agree with a lot of what she says; she apologizes unnecessarily for “offending me.”

Next week I’m supposed to do the counseling myself (with an experienced counselor watching). This afternoon I will spend all night in labor and delivery. Strange world.

I wrote that almost forty-five years ago during my third year of medical school and a month shy of Roe v. Wade’s fifth anniversary. This year’s may be Roe’s last.

The physician, Dr. Richard Ragsdale, was a kind and compassionate man whose face resembled Lee Marvin. He would gently explain to the patient what would happen and always gave her the option of backing out. He would close his eyes when doing a bimanual pelvic exam, as if he was trying to mentally visualize the uterus. When the procedure was over, he would help her sit up, remind her of what to expect that was normal or concerning, and ask if she had any questions.

Then, as now, providing abortions wasn’t easy. Dr. Ragsdale’s clinic was firebombed. He was forced to do pregnancy terminations in a local hospital after the Illinois legislature adopted licensing regulations for outpatient clinics that were impossible to meet. Dr. Ragsdale sued the State in 1985 (Ragsdale v. Turnock, 625 F. Supp. 1212 (1985)). The Seventh District U.S. Court of Appeals ruled the Illinois regulations unconstitutional and the case continued to the Supreme Court but was settled in 1989. Dr. Ragsdale died in 2004.

I believe a few inconvenient and irrefutable facts:

First, and most important, women aren’t capable of inseminating themselves. The single requirement for an unwanted pregnancy is a willing dick with viable sperm. No politician has introduced legislation regulating accidental fatherhood, but maybe they should.

Second, preventing unwanted pregnancies can minimize the need for abortions but that requires, among other things, affordable and easily available contraception. GoodRx.com provides cheap oral contraceptives and Depo-Provera online. An IUD can run $500-$1300 but can last up to 12 years. The Colorado Family Planning Initiative provided long acting reversible contraception to low income women, cutting teen birth and abortion rates in half. Condoms cost about a buck each, less if bought in a box of 12 or more, but they won’t work if they are stuck in a wallet.

Notice I said minimize, not eliminate. Any given pregnancy has a 10%-20% chance of ending in a miscarriage, also called a “spontaneous abortion.” Oklahoma wants to criminalize abortion “from the moment of conception,” which presumably would make inserting an IUD a felony. The State has also convicted a Native America woman of manslaughter for miscarrying her 4-month pregnancy. Texas’ draconian antiabortion law would potentially consider surgical or medical treatment of miscarriages a crime, equivalent to a voluntary abortion.  So much for “small government.”

Sometimes a pregnancy implants somewhere outside the uterus and this “ectopic” pregnancy is life-threatening. The choice is removing the errant pregnancy or letting the woman die when the tube ruptures. When I was a resident we found a live fetus the size of a rice grain in a gestational sac hanging out the end of the Fallopian tube and no, we could not just move it to the uterus. Conservative thinking would potentially consider this an abortion.

Every birth control method, even permanent sterilization, has an inherent failure rate. Several years ago I saw a 42-year-old woman in a rural hospital’s Emergency Department complaining of a week of bleeding and abdominal pain. She’d had her tubes tied thirteen years previously but never thought she might be pregnant, but she had a positive pregnancy test. I found 1,300cc of blood in her abdomen from a ruptured ectopic pregnancy.

Preventing unwanted pregnancies also requires adequate sex education and the political will to ensure it happens. Countries with comprehensive sex education have far lower teen pregnancy rates than the United States. Determined teenagers will engage in sexual activity, regardless of adult pearl-clutching and sanctimonious bullshit, so get over it.

Third, women with money will always be able to get a safe abortion, regardless of state restrictions or their personal religious affiliations and convictions. So will the pregnant mistresses of pro-life politicians who have a sliding scale of morality.

Finally, I don’t want someone telling me what to do, so no one should be telling any woman what to do!

“Since we all came from a woman, got our name from a woman, and our game from a woman. I wonder why we take from women, why we rape our women, do we hate our women? I think it’s time we killed for our women, be real to our women, try to heal our women, ‘cus if we don’t we’ll have a race of babies that will hate the ladies, who make the babies. And since a man can’t make one he has no right to tell a women when and where to create one.”
? Tupac Shakur

Danni and Sarah

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(I first wrote this 25 years ago. Perspective changes with time.)

I worked for a staff model HMO for nine years. Despite being a small cog in a sizeable organization, our Ob/Gyn department was like a second family to most of us. We knew about most of each other’s spouses (or ex-husbands). We shared our young kids’ accomplishments, antics and disappointments. We celebrated birthdays, expressed our condolences at the passing of elderly parents, and grieved together when a beloved young mother-to-be died in car crash. We had monthly department meetings at local restaurants after office hours, instead of trying to cram an agenda into a lunch hour.

Danni was the RN OB Intake Coordinator for our group. She was a gregarious soul with a kind heart and a good sense of humor.  She spent an hour with each new mother-to-be at their first OB visit, talking about what to expect during pregnancy, what to do (eat healthy, wear a seatbelt and keep your appointments) what not to do (smoke, drink, anything blatantly stupid or dangerous). She was usually smiling, even when one of her appointments sorely tried her patience.

If she was having a particularly stressful day I would go to her office and wrap my arms around her. She said I gave great hugs; this was back when it wouldn’t trigger a visit from HR. I remember her colorful cable-knit sweaters under her lab coat and the warmth of her cheek against mine as she hugged me back, providing a brief respite from the day’s aggravations. Sort of like Mom telling you not to worry, that everything would be alright.

Danni suffered unrelenting physical pain from a tragic injury more than a decade earlier. We all knew about it, but to hear her talk it was more of an aggravation, something she’d learned to live with. Or maybe it was to deflect from the emotional torment she carried and of which only a few were aware.

I left the HMO in 1994; Corporate dissolved the staff model a few years later because “you cost us too much money.” Everyone found other jobs in town; Danni got a position with a local clinic. Our family had been torn asunder; we drifted apart and some connections withered from neglect.

I wandered for a couple of years, working in two different practices and a couple of locum tenens jobs before being hired to set up a practice in a small Southwestern town. I’d wanted to leave the long, gloomy Midwestern winters I’d endured for three decades and was trying to get out from under crushing but self-inflicted debt. (It hadn’t occurred to me that I was abandoning my kids as well, something I would later regret.)

In February, five months into the new practice, I flew Danni and Elizabeth, another former staff member, out to help train my nurse and receptionist. My new staff had no experience with an obstetrical practice, and I was used to someone else handling patient education. In retrospect, my support staff may not have been receptive to the intrusion but I needed the expertise.

Danni promised to send me forms and other information when she returned home. I called her several weeks later since I hadn’t received anything. She seemed distracted and vague but assured me she would “get around to it when I have time.” I should have suspected something was wrong. That was the last time I heard her voice.
One evening she sent her daughter to spend the night with the neighbor next door.
And ended her pain forever.

*           *           *

Linda, a nurse practitioner I worked with, called me early the next morning, sobbing.
“Danni is dead!”
“What happened?”
“I don’t know.  She had her daughter Katie stay at her friend’s house last night. She found Dani when she came home to get ready for school.  I don’t know why, but they found a note.” 

She continued to cry.
“I remember she was suicidal when she left the clinic.  I remember telling you she could never do that to Katy and you told me ‘Don’t bet on it.’  I don’t understand.”
“I do,” I replied.  “I understand all too well.”

I talked with Peg later that day and told her what had happened.
“How are you handling all this?”
“As well as I can.”
“You know, I had a dream about you last week and I was afraid to tell you about it.  You and I were talking and you told me you were going to kill yourself in the same tone you are using now.   When I reminded you that you’d promised to keep going, you looked at me and said, ‘I was telling you what you wanted to hear.’  I heard the resignation in your voice.  How could you do that??  Don’t you realize how much it would hurt everyone, including your kids???”
“Yeah, but I wouldn’t be around to know it.”

Over the next 2 days we talked about suicide; Peg was very angry.
“It’s so selfish!  I don’t understand how she could calmly take her own life and leave her child with no one. There is always something else you can do.”

But for someone who has fallen into the abyss, such platitudes ring hollow.  I know because I lived on the edge for almost 30 years and peered into the darkness many times.  There comes a point when there is no more hope; when one has reached one’s limit of coping and can go no further.  A point at which getting out of bed in the morning takes all the energy one has.  There is nothing tangible to keep one moving, to make one want to take one more breath.  Danni had reached her limit after years of constant physical pain and believing she had to go it alone.  For all the people who cared and loved her, she finally could not continue.

The love of other people isn’t enough for some of us, because we don’t feel it is genuine or that we deserve it.  On some level, I had long viewed that conditional “love” in the context of Billie Holiday’s song, God Bless the Child:

“Rich relations may give you
A crust of bread and such
You can help yourself
But don’t take too much.”

Ironically, Nietzsche said, “The thought of suicide is a great consolation: by means of it one gets through many a dark night.”  I survived many of those dark nights and ultimately determined I didn’t want to jump into the void.

A couple of days later I got an e-mail from Liz.
“I got your message, thank you.
I feel numb.  I can’t believe it.  I will never understand. 
Please, David, never do this!!!!!!”

*           *           *

Sarah was a 17-year old-gangbanger and troubled youth. Her father had also been a gang member, but he had turned his life around and tried to steer kids away from drugs, alcohol and living on the edge. Age and a stark reminder of mortality is often enough to trigger such an epiphany in adults, but teenagers either think they are immortal, or doomed to a life that can never change, so why bother.

Sarah was drunk the night she and some friends were playing chicken on the Interstate highway that ran north of town. They would lie on the white line while traffic approached at Autobahn speed, then run to the shoulder at the last moment.  When Sarah’s turn came, she got up too late and was struck by a car.  The local newspaper called it “an unfortunate accident” but some who knew her said she’d been severely depressed.

I went to the visitation with a family who had a troubled, angry 15-year-old daughter. I learned that when she threatened to run away from home, Sarah had talked her out it.  “You don’t know how good you have it.  You don’t ever want to live on the street!”  Her friends and acquaintances, also “gangbangers,” appeared for the visitation, crying and holding on to each other for support.

I cried the tears I hadn’t been able to shed for Danni, and for those kids who felt they only had each other.   I cried wondering why it took death to arouse family and friends from their oblivious slumber. Twenty-five years later I know some aren’t receptive to being helped, no matter how sincere the efforts.

St. Mary’s Church was filled for the funeral.  The gang members had printed T-shirts with “Turtle” (her nickname) over the left breast, and a memorial on the back: “In loving memory of Sarah Jo, 1980-1997.”   During the eulogy Sarah’s cousin told the mourners, “If you love someone, tell them now.  You never know when it will be too late.”

The procession to the cemetery stretched for 2 miles.  After the priest finished, her friends released green and white balloons and sang for her.   I couldn’t hear what they were singing. Instead, I heard a radio in the background playing “Forever Young” and then “That’s What Friends Are For.”

Melissa, 8 years old, wrote her own goodbye:

I held my 13 year old son and told him I loved him, even though I chewed his butt incessantly and tried to make him walk the straight and narrow.  He blew it off, but deep inside I knew he understood and would always know that I loved him.  I’d like to think my dad would have done the same.

A parent’s worst nightmare is having to bury a child long before his or her time. 

A child’s worst nightmare is wondering what you did to make your parent commit suicide.

National Suicide Prevention Lifeline: 800-273-8255

Turtle © Can Stock Photo / shalamov

Happily, Ever After

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(I took a few months off because I didn’t have much to say. and I wanted the tangible rewards of “döstädning” (Swedish death cleaning). We emptied the storeroom Peg rented for her parents‘ things after her father’s passing. The memorabilia and the coming New Year’s Eve folderal prompted this memorial.)

Many people make resolutions on New Year’s Eve, most of which won’t last the month. But this one lasted a lifetime.

Mike was born in Chicago in 1919 to James and Anna Sullivan, immigrants from Ireland and Yugoslavia, respectively. They lived on the West Side of Chicago where the Irish and Italian neighborhoods met. His father worked for the railroads and his mother was a housewife; back then married women didn’t aspire to anything else. His little brother Johnny was born a few years later. Mike and his family emerged from the Great Depression intact but, like many from that time, he saved every little thing because, “you never know when you might need it.”

Mike enlisted in the Army when World War II started, earned a sharpshooter rating during sniper training, before becoming a tail gunner in a B-17 Flying Fortress. His plane, the Opissonya, was mortally wounded during Operation Tidal Wave, a raid on the Ploesti oil fields in Romania. Mike was badly wounded and his parachute was riddled with bullet holes. The bombardier, David Kingsley, strapped Mike in his own parachute, tossed him out the door and went down with the ship. He was captured and sent to a Bulgarian prison camp, returning home with memories and secrets he would only share with fellow veterans. When his wife pressed him for details many years later, he would say, “Honey, you don’t want to know. It’s not something I want to remember.”

Sketch from Mike’s diary done while in the POW camp

After the war Mike returned to Chicago and moved back to his parents’ house. A budding artist, he enrolled at the Art Institute of Chicago and then landed a job as a graphic artist. On Saturdays, he and his buddies would go to one of the many dance halls around Chicago for a night of revelry. Sometimes they would crash Italian wedding receptions because there was always great Italian beef and no shortage of gorgeous young women who loved to dance. The revelry would often last until the wee hours of Sunday morning, when they attended the sunrise. Mass before hitting the sack. He was a confirmed bachelor with absolutely no interest in settling down and raising kids. Or so he believed.

Gloria was born on the South Side of Chicago 1933, to Joseph and Nadezda Shiplov, the last of eight children. They emigrated to the United States from “the old country,” although which “old country” was always a mystery. They might have come from Yellow Russia (now Belarus), or maybe Russia proper before it became the Union of Soviet Socialist Republics.  Family members were always evasive about their history and any information pried from reluctant lips was suspect. There’s an old picture of Grandpa Joseph in a Cossack uniform, prompting speculation he may have fled the Bolsheviks. He arrived at Ellis Island with, according to his travel papers, a woman who was NOT Nadezda and whose fate remains unknown.

The only person who knew everyone’s secrets was old Muzyka, the undertaker for the Eastern European community, and he took those secrets to his grave. Peg says, “The Shiplov family crest should be engraved with “??? ???? – Everyone lies!”

Nadezda died when Gloria was two years old, and Joseph was ill-equipped to care for a tosed around among the siblings’ families until her sister Ann, twenty years her senior, and her husband John took Gloria in and raised her as their own.

Ann Morgan and Gloria Shiplov, age 6

Gloria graduated from Jones Commercial High School, a prestigious and rigorous institution that provided students a well-rounded education with business and personal training highly sought by employers. She learned secretarial skills and bookkeeping, but she dreamed of becoming a nurse. She was lucky enough to get a full scholarship to nursing school, on the condition that her family provide a small monthly sum for “incidentals.” Her father refused and never offered an explanation, so Gloria found a secretarial job at Teepak, a company that manufactured meat casings. Maybe his decision was rooted in Russian pride, or maybe he believed a woman should never aspire to be more than a housewife and mother. I’d like to think it was divine intervention, a little nudge in the direction of the inevitable.

On Saturday nights Gloria and her pack of girlfriends made the rounds, dancing with eager young men at the dance halls or sometimes with soldiers at the local USO. One sultry summer evening in July she and her best friend, Marge, went to a “28-and-older” dance, even though Gloria was only 22 at the time. Mike Sullivan was also at that dance, and at the time had been dating three or four women, including one who assumed they were engaged, although no such proposal had ever been offered. He was still footloose and fancy free, committed to remaining single.

That changed at 11:35pm.

Gloria may have noticed him first because she later wrote “Finally asked me to dance at 11:35pm July 2, 1955” in her bridal keepsake book. Twenty minutes later they went to Honolulu Harry’s Waikiki for their first date. That was a much different time as few women today would leave with a man she’d only known for 20 minutes. But the heart knows what it wants. Later he would tell his daughters “I knew she was the one.”

A few weeks later Mike was in Sault Ste Marie, Michigan, on his way to Canada and then Detroit to visit family. Never one to worry about minor details, he sent several postcards to Gloria “Loveship.” He lamented she was not with him in the hotel lounge to “sip the gin and tonic with me” and vowed to make up for the separation upon his return.

Gloria and Mike were inseparable. They celebrated Mike’s birthday at their favorite restaurant, Honolulu Harry’s that fall and her birthday a few months later.

New Year’s Eve 1955 was very special. They were gathered at the home of her sister and brother-in-law, Alice and Bill, to see in the New Year. At 7:40pm, Mike took Gloria’s hand into his, slipped a ring on her finger and said, “You’ll get the mate in six months.” When asked decades later why he didn’t formally say, “Gloria, will you marry me,” he replied, “There wasn’t any need because I knew she’d say ‘Yes!’.”  In June 1956, she “got the mate.”

Gloria and Mike’s wedding

Mike, the formerly confirmed bachelor, settled down with the love of his life. They had two daughters and moved to the suburbs in 1964. He worked as a commercial artist at several companies in downtown Chicago until retiring in 1989. He turned down any promotions that would have meant less time with his family. He became notorious for “train-skunking” – scavenging the METRA commuter cars for newspapers and things left behind – a habit which once netted him a new bottle of scotch. Gloria was a stay at home mom until the girls were in middle school; then she worked as an office manager and bookkeeper until she retired.

They had a special ritual they followed every New Year’s Eve. Gloria would remove her rings that morning and Mike would hold on to them. Later that evening during whatever gathering they attended, Mike would have a Manhattan and Gloria would have a martini. At 7:40pm, he would quietly take her hand, slip the rings back on her finger and ask her to marry him. It was a private moment upon which the family would never intrude. They did that for 47 years until Mike’s passing in 2003.

Sometimes there really is a “happily, ever after.”

© Can Stock Photo / FotoMaximum

The Mighty 1090

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I worked the midnight shift as an orderly at the local hospital during the summer of 1971, often stayed up late or all night when I wasn’t working so I could maintain the same biorhythm.  Sometimes I’d listen to the radio, which in the mid-1960s, fed us a steady diet of three-minute paeans to love, life and the pursuit of the fairer sex. The main sources of pop music in our central Illinois town were Chicago AM stations WLS and WCFL. WLS was the favorite with a host of memorable jocks: Art Roberts, John Records Landecker, Dick Biondi, Clark Weber and the irascible Larry “Uncle Lar’” Lujack.

Pop music started to change during the late 1960s to heavier stuff like Led Zeppelin, Rolling Stones, Crosby, Stills and Nash, Steppenwolf, The Hollies, The Kinks and The Who. Two of The Turtles joined Frank Zappa and the Mothers for a raunchy concert at the Fillmore East.  Even the Four Lads from Liverpool had gone to the dark side of drugs, mystical music, and infighting. John Lennon took a lot of shit for claiming the Beatles were more popular than Jesus Christ. We scoured the White Album’s inserts for clues to Paul McCartney’s “death.”

A few of my friends and I were the “goddam hippie-freaks,” as if small-town America had hippies in the early 1970s. High school dress codes banned long hair and beards. Girls still had to wear skirts, even during a -20° windchill winter.  There was no heavy drug use (at least of which I was aware). One of our classmates was found sitting up in a sleeping bag in a garage, dead after sniffing airplane glue. Don tried putting peyote buttons in a Dairy Queen strawberry milkshake only to promptly puke it up. Herb bought a test tube of marijuana – mostly stems and seeds – which we stared at intently while huddled in the back of his dad’s Econoline van. I imagined the police would bust in on us at any moment and we’d spend the rest of our lives doing hard time in Stateville among murderers and thieves.

Our band of gypsies gravitated towards less conventional groups, the stuff one would never hear on Top 40 radio: Pink Floyd, Emerson Lake and Palmer, Quicksilver Messenger Service, Peter Green’s Fleetwood Mac, Santana, Traffic, The Band, Grateful Dead and Hendrix. While our classmates listened to The Who’s Tommy, we were splitting our eardrums listening to Live at Leeds, Hendrix’s Electric Ladyland, and Roger Waters’ piercing scream in “Careful With That Axe, Eugene” from Ummagumma.  In 1969, Jefferson Airplane’s rebellious Volunteers was the first rock album to get “motherfucker” past the censors (although the OCR of Hair beat them by two years).

A year later, Paul Kantner released Blows Against the Empire, with collaborators Jerry Garcia, Mickey Hart, David Crosby, Graham Nash, and others. The album was a counter-culture fantasy about hijacking a star ship and leaving the earth for utopian pastures, getting a Hugo Award nomination.

One night, while fiddling with the tuner on my compact stereo, I stumbled across a world of music, largely foreign to small-town Midwestern ears, on a radio station out of Little Rock, Arkansas.

KAAY 1090AM is a 50,000-watt radio station in Little Rock, Arkansas. I could only pick up after 10 pm when all the smaller stations shut down for the night. Hearing it for the first time reminded me of when I discovered Radio Havana in 1967 on a leather-clad shortwave transistor radio my grandfather had given me. (Ironically, KAAY also reached Cuba, subverting the “ideological purity” of a generation of Cuban youth. Fast forward 50 years and the Stones play in Havana.)

From 10pm until 2am Clyde Clifford (real name: Dale Seidenschwarz), a laid-back guy with a smooth baritone voice, hosted Beaker Street on “The Mighty Ten Ninety.” It was four hours of “underground” music: much longer tracks; complex musical structures instead of the three-chord formula of pop music; and sometimes controversial subjects. The show’s intro – click here– used a segment of Jimi Hendrix’s If Six Was Nine. Later the intro used a snippet of “House of the Rising Sun” done on a MOOG synthesizer.

Beaker Theater followed at 2 am, broadcasting old radio plays. The only one I remember was a dramatization of Isaac Asimov’s “Nightfall,” a short story about a civilization on a planet with six suns goes mad when an eclipse that occurs once every 2000 years brings total darkness, something they’ve never experienced. (Click here to listen.)

The KAAY managers were too cheap to pay both a DJ and an engineer, so Clyde did both, broadcasting Beaker Street from the station’s transmitter site in Wrightsville, AR instead of the studio in downtown Little Rock. Between song tracks Clyde played ethereal background “music” from “Cannabis Sativa,” by Head, to cover the transmitter’s sounds. Occasionally it ran for several minutes, leading me to believe Clyde had either nodded off or was taking a bathroom break.

Beaker Street introduced me to obscure groups and albums. Spooky Tooth. The Flock. Hawkwind. Bloodrock. King Crimson. Black Oak Arkansas. Black Sabbath, long before Ozzy became an addled old man yelling “Sharon!” Sometimes I’d tape parts of the show with my cassette recorder. The nature of analog tuners meant the signal would periodically drift in and out, interrupting the track, but that was part of the charm when I listened to the tapes years later.

One of my favorites is Jamie Brockett’s “Legend of the USS Titanic.”  It’s a completely bizarre fictional account combining historical fact (Jack Johnson, was a turn-of-the-century black boxer), blatant inaccuracies (there was no U.S.S. Titanic), racial stereotypes (“Jews from Miami trading wives and Cadillacs and diamonds”), and modern drug culture (a dope-smoking first mate who carries around “four hundred ninety-seven and a half feet of rope”). The track, running a then unheard-of 13½ minutes, explains the ship sank after the captain, stoned out of his mind, went mano a mano with the iceberg.

Many people remember Welsh guitarist Dave Edumuds for his 1971 AM hit “I Hear You Knockin’.” I remember him for Love Sculpture’s album Forms and Feelings.  A heavy metal version of “Mars,” from Gustav Holst’s orchestral suite The Planets, segues into an “amphetamine-fueled rave-up” of Khachaturian’s “Sabre Dance,” which concludes with the last few bars from The William Tell Overture. (“Mars” wasn’t on the original U.K. Parlophone release of Forms and Feelings due to a dispute with the Holst estate, but was included in the U.S. Parrot release.) I kicked myself for not buying the album when I first saw it in the early 1970s before it went out of print. I spent the next four decades years looking for either an LP or CD version, finally acquiring the latter in 2008.

But one song was totally unlike most of what aired on Beaker Street. Late one night I heard “White Bird”, a haunting song by an obscure group with the unlikely name It’s A Beautiful Day. It was exquisite; I would think about it when I stared out of an empty hospital room window during my 2 am break. I began a frantic search for the album, eventually finding it at Arlan’s discount store in Peru, IL, about 30 miles from home.

Clyde left Beaker Street in 1972; the program continued with other personalities until it was taken off the air in 1985. The show was resurrected in 1995 on various Arkansas FM stations before taking another bow in 2011.

Now die-hard fans congregate on the Beaker Street / Clyde Clifford Fans Facebook page, reminiscing about the music that defined us and decrying what passes for contemporary music now. One can now listen to Beaker Street on Friday nights at 9pm Central on the Arkansas Rocks Radio Network.

Some would argue our music was better than what came before and after, but that would be missing the point. Every generation continues the tradition of adding onto that invisible road, paved with infinite combinations of just twelve notes, stretching back millennia. Our music was just a scenic turnout along the way.

Favorite Albums From High School
Jimi Hendrix – Electric Ladyland
The Who – Live at Leeds
Paul Kantner – Blows Against the Empire
Quicksilver Messenger Service – Happy Trails and Just for Love
Derek and the Dominos – Layla and Other Assorted Love Songs
Rolling Stones – Let It Bleed
Pink Floyd – Ummagumma
The Band – Music from Big Pink
Jefferson Airplane – Volunteers
The Doors – Weird Scenes Inside the Gold Mine (2-LP compilation)

Beaker Street Staples
Buffalo Springfield: For What It’s Worth
Black Oak Arkansas: Lord Have Mercy on My Soul
Chambers Brothers: Time Has Come Today
Spirit: Animal Zoo, Morning Has Come
King Crimson: The Court of the Crimson King
The Flock: Green Slice / Big Bird
The Animals: Sky Pilot
Spooky Tooth: Tobacco Road, I Am The Walrus
Vanilla Fudge: You Keep Me Hanging On
Mason Proffit: Two Hangmen
Bloodrock: DOA

Featured image: © Can Stock Photo / photoslb