That time I had emergency surgery in a Middle Eastern Hospital...

Yup.

It's been a helluva week.

Remember how we were recovering from being sick?

It just got so much worse.
In the wee hours of last Tuesday night/Wednesday morning, I had my left ovary, left Fallopian tube, and a gangrenous cyst the "size of an infants head" removed from my person.
It was SO not the week we thought we'd have.

David was set to have the week off - mid term break - and we had mapped out our days to include a few activities and lots of family time.

I still wasn't feeling great, and was sleeping a LOT.

Monday afternoon I woke up at 3:00pm. 

I mean...what?!? What was that about? I knew I'd been tired lately, and I've often joked that sleep was my Love Language, but this was a little extreme. 

I'd slept like 14 hours, effortlessly.

I came out of our bedroom, sheepishly apologizing for having slept the day away, and asking if everyone still wanted to go to the beach as we'd planned?

No, turns out everyone was enjoying a PJ day at home, and it was okay that I'd been MIA.

Whew.

I went in to take a shower, and noticed my hip was sore.

Must have slept wrong on it.

After my shower I tried to lay on the rug and do some yoga to stretch it out. 

The irritation kind of came and went, and I had a bowl of cereal. 

Over the next hour or so, it went from an irritation to pain.

And then pretty strong pain.

And then I threw up.

And then the pain got worse.

I went to lay back down in bed again.

Was this from the shot I'd gotten in my back at the doctor's the other night?

Was it still this damn flu bug our home had been cursed with?

I didn't know, but it was unrelenting.

By the time evening came, I was in a pretty bad way.

Dave put the kids to bed, and asked me if I needed to go to the hospital.

No, because what if it was just something silly like gas or something?!?!

The last thing I wanted was to go into an emergency room and find out I just needed to fart.

I tried pacing.

I tried laying down.

I tried stretching.

Nothing worked.

Ok, this was getting really, really painful.

I needed to be seen by a doctor.

I had David call our driver and have him come pick me up at our place...there was no way I was walking the one block to hail a cab myself.

Dave wanted to come with me, but the kids were asleep, and while we do have a handful of people we could call that we trust who could come stay here with them, lately they've not been sleeping well and instead getting up several times a night, and I didn't want them waking up to someone else being in our home. That would likely be very upsetting for them, and I just didn't want that.

Besides, I was sure it was likely nothing.

Dave didn't want to send me alone, so I told him to call our friend Tina.

That's right, Bahrain Tina.

=)

I mean who else would I go on a medical adventure in the Middle East with?!?!

Tina agreed to meet me at the ED.

 By the time Hussein pulled up in our parking lot, I was in a really bad way. David walked me to his cab, told him to take good care of me and text him once I'd arrived at the hospital, and to go quickly.

And go quickly he did.

He was FLYING down the streets, honking at people to move out of his way, and running very yellow lights.

(to be fair, this is how most people drive in Kuwait, but never Hussein, which is one of the reasons we call him)

I was writhing in the back seat. Moaning and throwing myself from one side of the cab to the other. It was not good.

He got me to the hospital in minutes, and asked if he should take me inside. No, I said, my friend is coming to meet me. 

As I was getting out of his cab, I dropped my water bottle. I tried to pick it up, but could not make a pincher grasp with my hand.

WHAT THE HELL.

I had numbness in both my arms, and literally could not control my hands.

At this point I really started to freak out.
Was I having a stroke or something??

I took about three steps towards the door, and was moaning in pain. Someone appeared with a wheelchair and I collapsed into it.

I was wheeled in to the ED and said "Doctor! I need a doctor now!" and was taken back. A nurse appeared and asked what was wrong.

I said "my side, my back, my stomach...so much pain. My arms are numb. They are tingling!"

I then proceeded to yell out my name, age, blood type, medications and allergies...because I legitimately thought I was going to pass out any second and knew that this was pertinent  medical information. 
They got me on a gurney and were asking me questions about whether or not I was possibly pregnant (I was sure I was not) and what I thought the pain might be from (I had no freaking idea) and gave me an IV of something which did nothing and so they gave me an IV of Tramadol which did a little but not enough so they gave me a shot of something directly into my rear end. 
That helped.
I still felt discomfort - bordering on pain - but it stopped the writhing.
I mean to tell you I had been writhing. The chux pad on the gurney beneath me was literally torn apart from my twisting and turning on top of it.
I had been moaning in pain and pulling at the hair on the top of my head. 
Never ever ever ever had I felt pain like that. 
When the meds had finally taken enough of the edge off that I could be examined, I gave a urine sample and had an abdomen exam.
The ED doc was suspecting kidney stones. 
He said he was "99.9% sure" it was kidney stones, and that I had a blockage. 
He said we'd need sonar to confirm this, but that a urine test would at least tell if I had an infection as well.
All my blood work (I guess they'd drawn blood somewhere in there?) had come back clear.
I'd heard kidney stones were excruciating pain, so I figured this diagnosis made sense.

After awhile, a new doctor appeared (I guess there had been a shift change) and a few nurses had come by smiling and said they were glad to see me talking and no longer just moaning from the fetal position.
I was glad too.
The doctor said my urine was clear, no infection.
I asked could this mean I still had kidney stones? 
Yes, apparently, but we'd need ultrasound to confirm. 
I asked to please be admitted and stay the night in the hospital. It was after midnight at this point, and I really was so afraid that the pain was going to come back, and I would be at home, away from all this help.
He at first said okay, that he'd go work on that.
Then he came back a bit later and said he could not admit me. My urine was clear, my blood work was clear, and my pain was controlled...under what terms was my admitting to be exactly??
Hard to argue with...I guess you can't convince an insurance that a patient is just FREAKED OUT to be in so much pain again, and wants doctors and medicine near by.
So he gave me a few prescriptions - one for an upset stomach, ironically - told me I had an ultrasound scheduled for 9:00am the following morning, and sent me and Tina on my way.
We walked over the the pharmacy to fill my meds.
I could hardly stand at the pharmacy without pain.
This did not bode well for the rest of my night.
We walked a block to a main road to hail a cab - because that's just Tina and I's THING, apparently - and I got home about 1:30 in the morning.

I tried to sleep, but was so damn uncomfortable I could not.

I left the house at 8:30 the following morning to head back to the hospital for my ultrasound. The kids were very anxious to see me in so much pain, and so the LAST thing I wanted was to leave them with someone other than a parent. I wanted them to have their Daddy with them. So I insisted David stay home, and told him I'd call as soon as I knew what my treatment plan would be.

I had barely gotten out of the building before the mind-numbing pain returned. I had to stop about every five steps and hold onto a parking cover rail for a moment before I could continue. 
By God's grace alone, I was able to hail a cab from down our remote driveway, and he came to me to pick me up.
On the way there I was moaning again and the arm tingling came back. It wasn't great, but at least this time I wasn't as scared, (I'd been told in the ED the night before that extremity numbing can be a side effect of debilitating pain) as I was fairly sure we had a diagnosis and I'd be getting treatment very soon.

Into the hospital, I lost the ability to walk. Had a wheelchair ride to ultrasound. Tried to check in, but turns out they find it difficult to do sonar on a person who is writhing in pain.
Back to the ED for another shot in the rear.
That calmed things down, back over to radiology.
Ultrasound shows "large ovarian cyst with torsion"...alrighty then, not kidney stones, but we have a diagnosis! Radiologist confirms this is the cause of my source of pain, and sends me back to the ED.
I text David...we have the problem, going to need surgery. Feeling relieved to have answers.
In the ED the pain starts up again, given some meds.
A gynecologist comes to retrieve me and admit me to her floor upstairs. In a wheelchair I go. Upstairs she wants to do a quick ultrasound to confirm before placing me in a room on her floor. She performs ultrasound, and declares this cyst is not in my ovary, that it is in fact in my abdomen and therefor I am not a gynecology patient and can not be admitted to her floor.
On the elevator ride back downstairs, I proceeded to vomit multiple times...I was feeling less relieved about my treatment plan as the morning wore on.

Back in the ED, new gurney.

The pain was become severe again, and the writhing and moaning picked back up.
Around noon they offered me another shot of meds.
YES PLEASE, FOR THE LOVE OF ALL THAT IS HOLY PLEASE GIVE ME SOME STRONG MEDICINE.
After that took effect, a surgeon appeared. He explained that the cyst was in my abdomen, and that it had torsion (ie, was twisting) and needed to be removed surgically.
Great. Let's do it. Where do I sign.
I'm not one who rushes to the idea of surgery, EVER, but I had been in so much pain I just wanted it to stop as soon as possible.

We discuss my surgical history (c-sec in 2010), and he mentions that I'll need a "quick MRI" to confirm the location of the cyst, then it'll be off to the Operating Room.
Great.. I'm totally on board with all of this.
Dave texts that the kids are really antsy to see me, so he wants to come visit.
Since my pain was controlled and I was no longer moaning, writhing, or vomiting, I agreed.
I was happy to see my people, and relieved to be able to show my babies that I was "okay" and talking normally and even smiling! The kids had each brought me a lovie (stuffed animal) of theirs to keep me company ;)

I only got to see them for a short visit before a wheelchair appeared to take me to my MRI. I had to have all metal removed for this, so David helped me take out my upper earring and my nose ring, and I handed him my wedding ring as well...which felt surreal. 
Our daughter started crying as I was getting in the wheel chair and I could tell our son felt really uneasy as well. David and I both tried to reassure them that everything was going to be just fine, Momma just had one more test to go do before the doctors could fix it all.
Watching my baby girl cry as she left was very, very hard...and it was precisely why I didn't want to leave the kids with anyone other than David. Had we been back home in Portland, I would have had grandparents or my sister or someone take them, but even though we've made great friends here in Kuwait, our kids don't know them super well just yet, and it's all still so new. 

Off to MRI. 
With AND without contrast, just to make it nice and lengthy.

After the MRI, one of the tech says to me "you have two cysts, one larger up above and one smaller down below. You will be having surgery urgently!"
Super. Let's get this show on the road.
But instead I'm taken into ANOTHER FREAKING ULTRASOUND.
If you're counting, this makes my THIRD for the day.
This time two doctors are looking at it, then they call in a third for consult. Then a fourth.
I'm not even kidding. Four physicians standing around me while giving me sonar.
They're trying to decipher how many cysts there are, and where exactly they are.
At this point my shot is wearing off, and I'm near the point of just asking for a general surgeon to simply open me up and look. I don't even care. Just slice me open and have a look that way...these imaging tests are taking too damn long.

All their discussions are in Arabic, so I have no idea what they decipher, but soon I'm in a wheelchair....and being taken back to the freaking ED.
(I later learned they were trying to figure out if there were two cysts or one...turned out to only be one, but it was very large and partially ruptured and draining into a lower area...hence why they thought possibly two)

I am laying on a gurney and call for a nurse...I tell her my pain is getting severe and can she please hook back up my IV of Tramadol?
She does.
Then not even five minutes later, she appears again, turns off the drip, and leaves.
Hmmm. 
I wait a few minutes and call out again.
And again.
A different nurse appears and I say "please turn back on my medicine, I'm in pain!"
She says "I'll go check..." and disappears.

This went on for awhile.
I could NOT figure out why they would not just turn on my IV drip?!?!

Finally around 8:00pm - when I'd been without medicine for EIGHT HOURS - I started crying. Weeping is more like it. I called out for a nurse, and when one appeared I just started begging..."why? Why won't you give me medicine? Why? I'm in so much pain! I'm supposed to be having surgery like hours ago!"

She hesitated, and then she said this:
"Your insurance has denied your admittance, and they've denied any more medicine for you. We don't know what to do..."

As I live and breathe, I don't know that I've EVER been so stunned in my entire life.

I completely lost my mind.

I started in "So you were just going to LEAVE ME HERE?! Just keep telling me you'll check and closing my curtain and LEAVING ME HERE TO SUFFER with absolutely NO PLAN to care for me?!? YOU SHOULD HAVE TOLD ME! I could have called my husband and he could have called the insurance! YOU should be fighting with the insurance!!! I HAVE CONFIRMED CYSTS!! How can they deny me?!? And HOW CAN YOU JUST NOT HAVE AN ANSWER?!?! Get me a manager NOW!!!"

"Yes madam" she meekly replied, and disappeared.

And I wept. And wept. And actually thought...this is it...this is how I die. Right here, in the emergency department in Kuwaiti hospital, abandoned and ignored because of an insurance dispute.  

I finally reached for my phone and sent David a text telling him there was an insurance problem and he needed to call the college's HR rep NOW and get it fixed. And I also sent Tina a text telling her I needed her to come to the hospital NOW and track someone down and fight for me to get some help.

A few minutes later my cell phone rang. I answered it, and it was a man from my insurance company asking what the problem was. I cried and yelled as I tried to explain. 

Would you believe he had the nerve to tell me to calm down?!?

I've never wanted to stab someone so desperately in my life.

I yelled for a nurse and just handed her my phone.
She disappeared with it.
Tina then appeared, with her husband and another friend. 
I was in a desperate way. "Please, please go find a doctor and tell them I need them NOW!" I begged.
She did ;).
She found a poor sap whose shift had just begun. 
I laid into him..."I had an MRI hours and hours ago...I had a surgery consult nearly NINE HOURS AGO...I have been in so much pain and no one will help me! They've all just LEFT ME HERE to suffer!!! I can't believe it. I just can't believe it!! What kind of hospital is this?!"

Poor guy.

He was like "ok, I'm going to take care of you...I don't know what's happened prior, I just started my shift, but I'm going to take care of you.."

"No, you're not. No one is!"  (I told you I was in a very desperate place!)
He left to go check on my paperwork with the promise he'd be back. I didn't believe him. Meanwhile, Tina, her husband and friend were all trying to help get whatever paperwork sorted out that needed to be sorted out so I could get surgery.
The end details are foggy (probably from the mind-numbing pain I was experiencing at the time it was all being sorted out) but apparently all the hold up had something to do with one damn form being incorrectly sent. 
That doctor actually DID return, and asked a nurse when my last dose of pain meds had been. "Around twelve noon" she replied. To his credit, he looked legitimately pissed off about this. He ordered something for my IV, but warned me it would only help so much because I WAS going to have surgery soon so they couldn't give me "too much".

Soon I was being wheeled upstairs to be admitted for surgery.
At this point it was 10:00pm. If you're keeping track, that's THIRTEEN hours after I'd arrived at the ED at that morning.
When the nurse was taking my vitals in the pre-op bed, she says "so you're having some abdominal pain?"
Oh sweet Mercy. Tina and I exchanged worried glances.

The worried glances continued as no one worn gloves while they did the antibiotic skin test, or IV hook up, or blood draw. And the worried glaces continued as I explained I'm allergic to Sulfa Medicines, and the nurse said "soapa? soap? You're allergic to soap?"

Oh sweet Mercy again. I was wrong earlier. THIS is how I die.

I spelled out S-U-L-F-A (and then also S-U-L-P-H-A, just to be extra cautious) for the nurse and she wrote down what I spelled, clearly still not understanding.
The surgeon came in, we discussed my history, medications, chronic conditions, and for the first time in several hours, I had confidence that someone knew what was going on and was going to take care of me. He said they'd continue to get me prepped, and that they were prepping "the theater" at the moment as well.
Then the anesthesiologist came in, and while he was very kind, I gave my history, medications and conditions for the billionth time that day, and even Tina had to ask "does she have a chart somewhere for reference? She's given this same information multiple times..."
It was ridiculous.
A nurse helped me change into a gown and put on a hairnet.
Around 11:00pm, finally, it was time to go to the OR.
Tina followed my gurney as far as she could (bless your heart, friend!) wished me luck, and promised me she'd update David.

I remember being wheeled into a room of the side of the OR, and just waiting. Waiting and writhing in pain. Moaning. At one point someone in scrubs and a mask came in to ask me if I was alright... "no, I'm in so much pain...please, hurry and start the surgery..."
"Soon, madam"
I just laid there and cried. I felt scared, and SO very out of control of everything. I was in too much pain to even formulate prayers, so I just recited scripture in my head and sang praise songs and hymns to myself.

** I believe this to be the beauty of liturgy, and liturgical prayer...while it may seem to lack emotion while memorizing and "preforming", it can be spiritual to recall and stand in the gap for praise and prayer when your spirit is lacking**

I also remember asking God to please, please let me wake up from this surgery.


And I did.

I have vague recollections of being in recovery. Nurses were smiling and held up some large, clear container with a big black ball in it and told me that had just been removed from me. 
They seemed so proud.
It was disgusting.
I threw up all over myself.

The nurses wiped my face for me and changed my gown, and then shortly after, they took me back to my room upstairs.
It was after 3:00am at this point.
Sweet Tina had left a note letting me know the surgery had gone well, and that she'd notified David. Once she had spoken with my surgeon and learned I'd made it out okay, she headed home. Did I mention she's smack dab in the middle of writing deadlines for her dissertation? 
Yeah, she is. And yet she'd willingly come spend HOURS withe me in the ED the night prior, and come again for HOURS that night as well. Now that is a good person =).

I remember the nurse handed me the phone, and David was on the other end. We talked for a minute, and then I handed the phone back to the nurse.
I don't really remember the rest of that night.


I woke up the next morning, groggy and in pain. 
Do you know what they give you IV's of post-op here in Kuwait? 
Paracetamol.
Which is acetaminophen.
Acetaminophen ONLY. Not like acetaminophen and Vicodin, or something. Nope. Non narcotic. 
I had a cyst partially rupture inside of me, and my ovary and tube removed, and the cyst pulled away from my bowel...and they gave me IV after IV of Tylenol.
(Full disclosure: they did give me one box of Solpadine upon discharge...but even that is a mild dose of codeine.)
I met the doctor doing rounds that morning who checked my incisions and the surgery drain I still had in place, and informed me that I had my left ovary and Fallopian tube removed, as well as one very large cyst. He said my surgeon would be in later to check on me and give me more information.
I slept off and on for a bit, and then around noon called and talked to my husband. I was so happy to hear his voice.
He brought the kids down for a quick visit. Seeing them made me SO happy. And they were happy to see me "better" as well. 
The kids were super gentle with me, and said they were ready to take good care of me when I came home ;).
We'd learned I'd need to stay another night, so after a bit they headed back to our apartment.

That afternoon my sweet neighbor Reem came by the hospital to visit me.
While she was there, they *finally* approved my liquid diet and brought in some food, (at this point it was Wednesday afternoon, and the last time I'd had anything to eat was Monday evening) I was still so weak, the woman actually spoon fed me my broth.
Talk about humbling. 

That evening I saw my surgeon, and he was so proud as he talked about this giant, gangrenous cyst he'd removed from my body. Apparently it was HUGE. And it was twisted in crazy ways, it had cut off the blood supply to itself and therefor caused some gangrene. It was partially ruptured, and he used the words "devoured" my ovary and tube. He apologized for not being able to save them, to which I said that was no problem...I already have two healthy children, and we'd decided over a year ago that we were complete in the bio kid department (still open to adoption sometime down the road...). He also informed me that the cyst had adhered to my colon, but he'd had his assistant lift up my bowel, and he was able to untangle the cyst from it and spare my colon, completely in tact. 
Thanks be to God.
I'm SO grateful for this. 
Seriously, I was done with that old tube and ovary, but my colon?!? I'd still like ALL of that for as long as possible.
He said he had every reason to believe the cyst was benign, but of course it was being sent to pathology anyways. Then he told me to rest and that he'd see me the next day.

That night, I was struggling with pain, and having a really hard time settling in to fall asleep, so I asked if I could get some stronger meds, and the nurse asked if I wanted a shot of pain meds directly. Remembering how those had calmed things in the ED, I quickly agreed.
Before administering, she took my vitals. Turns out my blood pressure. was slightly elevated. 
It was like 140/90...which is high, but not crazy high.
And hello I was in pain and also had been through an eventful 48 hours, so the fact that my bp was elevated did not surprise me.
But the nurse did not like it, and insisted I have an IV of Lasix before anything else.
Lasix is a diuretic. 
Which means I then spent the next several hours getting up to pee every thirty minutes or so.
This did very little for my pain, and absolutely zero for my ability to sleep.
I finally gave into the fact that I was not going to rest and flipped on the TV.
Turns out, in the middle of the night on Kuwait Satellite Television, you can find a movie or two. 
I watched "The Social Network", then "Rat Race", "Bad Boys II" and then two episodes of "How I Met Your Mother" came on, then it was only Arabic Soap Operas. 
It was a long, long night.

The next morning I was pretty exhausted and still in a decent amount of pain, but really eager to go home so I could attempt to actually sleep. The rounding doctor said it wasn't his call if I could discharge or not, and that I might have to stay another night, as going home with a drain still in is risk for infection. It'd be my surgeon's call, and he wouldn't be in until later.

I sent Dave a text with the news, and said I'd update when I knew anything.

Luckily, my surgeon came in around 11:30am. He said I could go home!!! I was so happy!! He felt like as long as I promised to be careful and sterile while emptying my drain, the risk of infection was very low and he agreed I could rest better at home.
HOORAY.
I called Dave and told him to head on over to the hospital and pick me up!!

Dave and the kids arrived around noon.
To make an already VERY long story just that much shorter, I'll spare you the details and the bitching and just say that it was over FIVE HOURS later that I was finally discharged.
Paperwork confusion, shift changes, etc.

Whatever. 

The very second that I was allowed to, the four of us walked slowly out of that hospital. I was not waiting ONE MORE MINUTE for them to get a wheelchair. We hailed a cab, and as David lowered me into it, he explained to the driver that I'd just had surgery and to PLEASE drive VERY SLOWLY.
He did. 
David paid him extra.


Things have been slow going since we got home. Recovery is going to be a process. I'm super slow to go from a sit to a stand, and vice versa...no lifting for FOUR WEEKS. Sleep has been difficult to come by. I have an incision above my belly button, one on my left side and two on my right (add in my c-sec scar, and I have a funny looking but complete baseball diamond ;) ) so it's pretty much laying flat on my back or nothing at all. I have struggled a bit with anxiety as well...my first few nights at home, whenever I laid down and closed my eyes, I felt like I was being rolled on a gurney again, and I'd panic and open my eyes and it'd take me a few minutes to orient myself...it all just came on so suddenly, and it was so intense, I'm sure it'll be awhile before I've fully processed it all.

 But, I had the drain removed last Saturday evening, so I can shower now! Hooray! 

Two days after discharge, David spiked 102 fever...today is his first fever free day, but he's still got a wicked cough.
And our son joined him with 103 fever of his own, and a nasty cough as well. L had a few puking episodes too, and poor David had to care for him, even though he felt miserable himself. I just CAN NOT risk getting a tummy bug right now...my abdomen can not handle that.

It's hard to abandon all the parenting of a sick child to David, especially when he's so sick himself. But, he's a trooper and really handling it well. 
I'm grateful for such a partner in life!

And we've been so blessed with amazing support over here.

That's the thing about a Country full of mainly expats - nearly everyone here is without extended family.

Reem has sent over several meals, and my homeschool co-op has a meal train set up with TWO WEEKS of dinners coming our way. 
Yesterday one of my favorite friends here (originally from Spain, but lived in Portland for a bit before moving to Kuwait!) sent her housekeeper over for FIVE HOURS to completely clean our apartment. 
I mean...are you kidding me?!?

When I insisted I pay for this service, Nathia refused, saying when her baby was born, her friend had sent a housekeeper over and paid for it, and this was her way of paying it forward.

And I've heard story after story like that. The first two homeschool moms to bring dinner said similar things...that they'd been in predicaments like this before and had to rely on the help of others, and that they were happy to have the opportunity to pay it forward.
Everyone has been so full of grace towards us.

It's incredibly humbling to need to lean on so many people, especially people we've only recently met!

But I'm learning it's not the worst thing in the World to be humbled...perhaps sometimes God allows it in our lives to show us that even if you ignore the dishes and forget to take out the trash and the kids wear the same pjs for three days straight and no on eats a vegetable in six meals and Facebook goes unchecked and people you only recently met see you get an injection in your bare ass and you need strangers to make your family dinner and you can write your name in the dust on your furniture...the garbage man will still come. 
The ocean tide will still come in and go out.
The sun will still rise and set.
The Earth will continue to spin.
Everything will continue to go on, even if you take a really long nap in the middle of the afternoon.
And maybe...just maybe...you're not as important as you thought you were, and the majority of the daily stress you feel is actually self-imposed.

So, there's that.

And now, for posterity sake, here is a few pictures of the drama...be warned, the first one is just the kids playing in my hospital bed while waiting for me to be discharged. The second one is a picture of the drain I came home with.
The next four are pictures the surgeon gave me of the giant beast of a cyst that he removed from me...and they're pretty gross looking, so don't scroll down if you don't want to see it!

See that hot dog looking thing? That's my Fallopian tube...cracked and bent from the torsion.

The surgeon said it was the size of an infants head, and based on that size, that it had been there for years.
I had NO IDEA.
I'd had my annual women's exam in August, right before we left for Kuwait, but it must have just not been palpable on exam. 

It's out now, and I hope to never, ever experience one again!