Tales From the Dark Side, Part II

In following up to yesterday’s post, I want to address my answer to the question, “Given the chance, would you have RNY again?”

WLS blogger Melting Mama, has a nine-minute YouTube video that explains why she wouldn’t. If you haven’t already, please watch the video (at the top of yesterday’s entry) before reading this. It’s not that MM wouldn’t have WLS, it’s just that given the choice, she would have picked an alternate procedure.

MM’s WLS journey is similar to mine in that we both went under the knife when we were in our 20s, both were over 300 pounds at the time, both had RNY and both now suffer from anemia and hypoglycemia as a direct result of that surgical procedure.

Yet now, more than three years later – four for her – we have very different views on what path we’d take if we could go back in time.

Why?

Because of one very key difference: MM was a very healthy 20-something who just happened to tip the scales at more than 300 pounds. I, on the other hand, was slowly dying in a 27-year-old fortress of fat. That’s the difference that makes our post-op experiences worlds apart.

Here’s my laundry list of pre-op concerns:

1. Chronic joint and back pain (I popped Darvocet and ibuprofen like candy);
2. High blood pressure (filled my first prescription for the condition at 21);
3. Debilitating migraines;
4. Infertility;
5. Chronic swelling;
6. Difficulty breathing;
7. Lack of mobility;

At 27, I felt like I was 80. I worked so hard to pretend the above conditions weren’t a problem and that I was “healthy” despite my weight, that I was exhausted by the end of the day. I had been morbidly obese since childhood, and my body was ready to collapse under its own weight.

After a long talk with a compassionate, yet direct, medical provider, I realized that I was on the cusp; my obesity was just beginning to catch up with me. I could continue down the path I was on and face increasingly severe co-morbidities or I could do something drastic to lose weight in an attempt to drastically reverse my course.

I chose the latter, and I haven’t had a single regret since.

Even when writhing in pain from a life-threatening bowel obstruction, I said with confidence that I would do it all over again because one day of life in a normal-size body is sweeter to me than any number in my pre-operative form.

But let’s get two things clear:

1. I DO NOT feel that way, because I’m “thin.” Go back and read my early posts – from before I had surgery – and you will see that I was terrified of being thin. It was a foreign concept to me at the time, something I could not wrap my brain around.
2. Surgery wasn't a cure-all for me. I still suffer from some of my pre-operative health concerns; they are just easier to manage at this size.
   

At the end of the day, my life is truly better now than it was in 2004 when I started my journey.

In my opinion, MM is not a whiner. Every word she says is true. We just have a different perspective on our situations. MM is right on the money when she calls WLS a trade-off. You give up obesity in exchange for other concerns or issues. In her case, the juice isn't worth the squeeze. In mine, it is.

She may not have had a bowel obstruction, but her hypoglycemia and nutritional deficiencies are much more severe than mine; I don’t suffer seizures nor do I need round-the-clock glucose monitoring. I also think that I’ve gotten more diligent after-care than she has – even when that bowel obstruction went misdiagnosed for six freaking months.

And I will say one thing very plainly: Reactive hypoglycemia is a nightmare.

MM says it best with the succinct comment, “Yeah, I look good. But what does that matter if I’m dead?”

If I ever came close to regretting bariatric surgery, it was when I became hypoglycemic. It’s difficult to articulate what it’s like other than to say it feels like your body is your enemy. Between that and the anemia presenting themselves at the same time, I felt like I was at the brink of insanity. The emotional and physical toll of hypoglycemic episodes were debilitating for me until brought them under control with the help of a caring, knowledgeable doctor a few months ago.

This last year has really been tough. I won’t lie. But in my situation, morbid obesity was still tougher.

Tales From the Dark Side, Part I

This video, courtesy of WLS blogger Melting Mama, is a must-see for anyone considering bariatric surgery. The picture she paints is grim reality that more pre-ops need to be exposed to. It’s a nine-minute video but it’s worth the time.

It’s been almost 3½ years since I had gastric-bypass – roughly about six months after Melting Mama. Our stories are similar in many ways: we were both over 300 pounds before WLS, we both were under 30, we both had roux-en-Y procedures, and we both suffer from anemia and hypoglycemia as a result of our surgical procedures.

Despite those similarities, though, we have different perspectives on our surgeries. Melting Mama would not have RNY all over again; I would.

I don’t want to steal the video’s thunder but it addresses the biggest issue I have with the popularity of surgical weight loss: LACK OF EDUCATION.

I remember my WLS orientation like it was yesterday. After six months of waiting, I was finally at Kaiser SSF to get more information on bariatric surgery. Like Melting Mama, I wanted the LapBand; it was less-invasive than gastric bypass, had no malabsorption and led to more gradual weight loss. I was also talked out of it when the surgeon at orientation informed me it was not covered by Kaiser and then gave me his laundry list of reasons why it was a bad idea anyway.

Beside that, there was one thing that struck me as odd about orientation – my fellow pre-ops didn’t seem to have a clue about bariatric surgery or what they were getting themselves into.

At this point, I had spent months poring over articles and research about WLS. I had interviewed people who had various procedures at various times. I talked to people with life-threatening complications and ones whose post-op journey was smooth sailing. I was armed and dangerous with more knowledge than my own physician when I marched into his office and asked to be considered for Kaiser’s program.

My cohorts at orientation, however, seemed to know little more than RNY made Al Roker and Carnie Wilson lose lots of weight and that they looked thin and beautiful. I remember one man who was downright outraged when he was told he’d have to limit his intake of sugar.

“But Al Roker says he can eat whatever he wants; he just eats less.”

It was hard not to roll my eyes.

I sat through three similar group classes before making a big decision: I would document my journey in writing and share it with the world.

Up to that point, I had intended to keep my surgery private. Like many of my friends, I was merely going to have “abdominal surgery” and let people think I was having my gall bladder removed or whatever. I didn’t want to make myself a spectacle. I didn’t want to open myself up to negative comments. I wasn’t even going to tell my family.

But the reactions and comments of the pre-ops I encountered in my journey showed me there was a dearth of reliable information on the subject of WLS that was easy to access. It also showed me that when it comes to losing weight, few people read the fine print. They are so intoxicated by the idea of being thin, they don’t pay any attention to the price they may have to pay. In short, they hear what they want.

So, my mission was simple: I would write a column dedicated to the subject with the goal of educating those who wanted or needed bariatric surgery and the general public. I wanted people to understand the seriousness of the decision, the dangers of the surgery and the fact that it requires a complete change in attitude and habits. I figured that since I had already done all the research, I could make it easier on others who followed in my footsteps to be as educated as I was when it came time to go under the knife.

Sadly, I overestimated my peers. Since I started this journey in 2004, I have only come across a handful of pre-ops truly willing to weigh the pros and cons of surgery. Even more sad are the number of post-ops who actually go on to make the changes necessary for success.

Annual Lab Results: The Human Pin Cushion Speaks

It's that time of year again. You post-ops all know what time I'm referring to. The time when we head to the doctor a leave with a handy-dandy lab request form in hand that has more boxes marked on it than unmarked, leaving us to wonder whether it would have just been easier for the doctor to write a note saying, "Check for everything but ... "

My lab results weren't that great last year. Both my blood sugar and iron levels were low. But with my employer changing insurance providers and then me taking a new job that offered other types of insurance plans, I had a hard time keeping track of things.

I met my PCP last week and instantly liked him. Merced may have a shortage of physicians, but so far, I think the ones we do have are top notch. He ordered a full course of lab tests for me and referred me to a nutritionist to discuss my hypoglycemia.

At the lab, I struggled not fall asleep as the technician drew eight vials of blood. I made a bee-line from the lab to a food source when it was all said and done.

My results came in early this week. I wish I could say I was surprised by them, but they only served to confirm what I already knew: I'm a bit out of whack.

First the good news: My cholesterol is 167. My risk level for cholesterol-related heart disease is 0.67. Average risk is 2.34-4.13. My doc is very happy. The nutritionist says I can eat all the cheese I want. Must be why I like her so much ;-)

Now for the not-so-good news: I have mytocytic anemia, most commonly referred to as iron-deficiency anemia. Most common, most easy to treat. The main concern is that I've been supplementing daily yet my iron levels are half of what they were a year ago, and my organs are not getting the oxygen they need. This is why I'm so tired and why I can't sustain physical activity for very long.

Here are my results for perspective:
Ferritin -- 1 (normal is 10-154)
Total Iron -- 22 (normal is 40-175)
Hemoglobin --- 10 (normal is 12-15)

Thought my ferritin level is in the toilet, the nutritionist I saw today said she doesn't recommend infusion therapy unless total iron is 10 or less, or hemoglobin is 7 or less. It's her opinion (she's also a family practitioner) that I can afford to try a higher dose of oral therapy for six weeks to see if that improves my levels. If it doesn't, then she'll combine oral therapy with weekly injections. Transfusion will be her last course of action. We will continue to monitor my iron levels every six weeks until I get in the normal range.

I've been taking 20mg of chewable iron daily. She's prescribing a new type of iron supplement that's supposed to be really good for women in general, but has also shown great results in bariatric patients. It's called Repliva. It's set up like birth control pills, where you take one active pill a day for 21 days and then an inactive pill for 7 days. Apparently, the body absorbs iron better when it gets a little break in between supplement cycles. Repliva is said to be more bioavailable than other forms of iron, because it contains B12, Vitamin C and Succinic Acid, which all act as binders to improve absorption. So, in theory, my body will absorb all 150mg of my daily dose. It's available by prescription only, and there is a chance that my insurance company won't cover it. But if it's not covered, I will figure something out. I can't afford not to supplement my iron intake. I'm not the type of person to cut corners when it comes to my health.

I really like my nutritionist. She gave me a glucometer so I can test my blood sugar levels daily and also gave me a plan of action on how to better control my hypoglycemia. I feel like she really took her time explaining reactive hypoglycemia to me and giving me additional tools to manage it. For instance, she told me that reactive hypoglycemia is much more common in the morning, which explains why I have such issues after breakfast that can lead to me ping-ponging all day to achieve balance. The solution may be as easy as eating only protein for breakfast. Following the same logic, that would mean that if I do want to indulge in a carbohydrate, dinner is the best time to do so.

Aside from logging my meals and testing regularly to find patterns, my immediate goal is to figure out how much carbohydrate my body can handle at one time and then ensuring I get a steady dose of that level throughout the day. This should alleviate my problems with fluid retention and bloating. I'm starting with 100 grams of carbs a day, split equally (20g) through my five meals. She prepared me for the need to juggle as my glucose monitoring reveals a pattern. For example, she said I might find that I have to limit my morning meals to only 10 grams of carbs but can boost my afternoon and evening meals to 30 grams.

Long story short, she did a lot to make me feel that all is not lost. That my hypoglycemia can be managed. And though it will take patience and discipline, I feel like she's willing to partner with me in figuring out my specific needs.

Melting Mama

I've become hooked this week on reading other blogs related to surgical weight loss. There's an abundance of them out there, and each has its own merits. Take Melting Mama, for example.

The site's owner, Beth, is a Bostonian about my age who once topped the scales at more than 300 pounds. What I love most about her blog is its snarky tone. She's had a slew of complications since WLS, and she doesn't shy away from them. I appreciate that about her, because as I've said, this journey isn't all peaches and roses -- and I think more people need to be aware of the risks associated with it.

So, take a sec and check out Melting Mama, and then click back here and tell me what you think.

The dark side of WLS

In the 18 months that I have been writing about my decision to have bariatric surgery and my subsequent journey toward a healthy weight, I've tried to paint a clear picture of my overall experience.

But there have been some topics I've steered clear from for fear that they are too unpleasant for general consumption. The fact is that bariatric surgery is not all peaches and roses. No two patients have the same experience, because every body reacts to the anatomical changes in a different way. Some post-ops feel as if they've never had surgery, because their experience is that unremarkable. Other post-ops experience side effects so embarassing they fear leaving the house. And it's those side effects that are the topic of today's post.

Gas
There are two types of gas that bariatric patients suffer from: pouch gas and intestinal gas. Pouch gas is the easiest to deal with. Any over-the-counter gas aid with simethicone will dispel pouch gas and ease the pressure and pain.

Intestinal gas is the most painful and problematic. No over-the-counter gas aids work well in the intestinal tract. However, Digestive Advantage markets an over-the-counter pill that prevents gas in the intestines. The once-daily pill must be taken daily to work, and takes a few days to become effective, but it drastically reduces the amount of intestinal gas one experiences.

The final issue with gas is that a few patients -- particularly those who have duodenal switch -- experience flatulence with such a pungent odor that it alienates them from the world outside. They don't want to be alone with themselves, much less with anyone else. This problem can be particularly traumatizing in some patients who find their world even smaller after weight-loss surgery than it was when they were morbidly obese. For these post-ops, Devrom can be a godsend. Devrom is an internal deodorant that works to neutralize the odor in gas and excrement. It's not pretty to talk about, but it's a tool that provides post-ops in this uncomfortable situation with some measure of freedom.

Constipation
Constipation is a common problem after bariatric surgery. Decreased consumption of food and fluids, combined with protein supplements, make for a situation where things don't move. Constipation may seem like no big deal, but if it goes on too long, it can lead to hemmorhoids, fistulas and obstructed bowels -- all of which are painful and can be dangerous. The best way to prevent constipation after gastric-bypass is to consume at least 64 ounces of water a day. Other post-ops advocate taking stool softeners and/or fiber supplements daily to add some bulk to the intestines and to encourage everything to keep moving. Those are great preventive measures, but what does one do if constipation is already a problem? Milk of Magnesia and Smooth Move tea are excellent solutions. They are non-stimulant laxatives that help solve the problem of constipation in relatively short order.

Diarrhea
Though more rare than constipation, diarrhea can also be a side effect of bariatric surgery. Aside from the social discomfort of dealing with diarrhea, constant loose bowels can also cause dehydration. Depending on how long it's been since the patient had gastric-bypass, there are a few solutions. Eating bananas can firm up bowel movements. For patients at least one year out, high-fiber cereals can add much needed bulk. Another option is to use fiber supplements. Fiber supplementation is a good solution, but it takes time to kick in.

Stupid is as stupid does

Originally published March 17, 2007, in Our Town for the Tracy Press.

The word "stupid" is not one I use often. It was an "ugly word" in my childhood home, meaning it was barely better than profanity. The word still makes me cringe. I’ve even got my husband trained not to use it in my presence.

But sometimes, there is just no other word that fits.
And I’m here now to confess that when looking back on when I fell ill in late January, I am stupefied by my own stupidity.

False sense of normalcy
A lot of gastric-bypass patients talk of being normal, but most of us realize our view of normality is skewed. Normal people don’t eat whatever they want without gaining a pound, no matter what those of us who have been obese tell ourselves. I came to terms with that fact about a year ago.

What I didn’t come to terms with, however, is that I’m not anatomically normal and never will be again. That’s easy to forget after losing close to 200 pounds in a two-year period. My exterior looks normal to the rest of the world. Few people would guess I’ve been morbidly obese for most of my life, and sometimes, I buy into that fantasy.

Take that night in late January when I first realized I was seriously ill. As I mulled over whether I was in serious enough shape to warrant my best friend and husband trekking into the mountains on a work night to pick me up, I had some moments of clarity that didn’t make me feel like the brightest bulb in the drawer.

What’s the worst that can happen?
Trying to convince myself of how silly it would be to have them drive all that way for nothing, I tried to imagine the worst-case scenario. I was one of the few guests at a rural cabin resort. There were no neighbors to hear my cries for help if I were to become truly incapacitated. No phone in the room to call the operator for help. I had my cell phone but didn’t have the manager’s number programmed in it.

Then my thoughts darkened. What if I were to lose consciousness? Nobody would even consider looking for me until an hour after checkout. Looking at the clock, I realized that a lot could happen in the next 14 hours or so. I also knew I was dehydrated, having consumed only about 4 ounces of water in the previous day.

Helping those who help us
I tried to be objective. If I were to pass out, either from the pain or from whatever ailed me, what would emergency personnel think? How would they help me? I didn’t have a MedicAlert bracelet to tell rescuers I was a gastric-bypass patient. My doctors warned me to order one before I even had surgery so that in an emergency situation, it could speak for me if I could not speak for myself. But I never made the time to place the order. It seemed inconvenient to figure out what to have inscribed on it, and though it wasn’t pricey, there always seemed to be better uses of my money.

I considered typing out my medical information and symptoms on my laptop but would medics really think to look there for clues? There was no way to be sure.

I finally called my husband and told him to come get me. Though I still had no idea of the severity of my condition, I realized I was safer at home with someone to help me than all alone in an unfamiliar, isolated area.

Stupid is as stupid does
To be stupid is to act in an unintelligent manner. Ignorance, on the other hand, is to be uneducated. Ignorance is forgivable; stupidity is not.

In hindsight, here were my stupid moves:

• Not seeking help sooner — There is no guarantee that earlier medical attention would have led to an earlier diagnosis, but I knew the dangers of dehydration and the signs of bowel obstructions long before I ever had gastric-bypass surgery. The moment I realized I could not keep water down, I should have called my husband to pick me up.
• Staying alone in an isolated area — When I was told to choose temporary lodging for my business trip, a quiet mountain resort sounded like the perfect getaway. And in some circumstances it could have been. But it was not the smartest move for a woman traveling alone.
• Not ordering a MedicAlert bracelet — Gastric-bypass patients have some serious limitations when it comes to medical care. NSAIDs like Aleve, Advil and Motrin can ulcerate our delicate gastric pouches. Nasogastric tubes, which are inserted through the nasal passage and into the stomach, cannot be used, since access to the remnant stomach is cut off by gastric-bypass procedures. Attempting to insert an NG tube blindly can perforate the gastric pouch — not a good thing. The other benefit to a MedicAlert bracelet is that it can list allergies. Because I’m allergic to a couple of commonly used drugs, that’s something that should be a higher priority for me.
• Not packing my vitamins — What happened to me had absolutely nothing to do with vitamins. However, I know better than to miss a single dose. The malabsorptive nature of my altered anatomy puts me at risk of vitamin deficiencies. There are few things more important than taking my vitamins each day. I knew when I left Tracy that I had forgotten to pack them. I decided that it wasn’t worth the effort to go back home to retrieve them. After all, I was only going to be gone five days. Five days without vitamins would not kill me, but it’s still stupid to rob my body of vital nutrients out of laziness.

No immunity from complications

Originally published March 3, 2007, in Our Town for the Tracy Press.

I’ve been fortunate since having gastric-bypass surgery two years ago. I haven’t had to deal with nutritional deficiencies, strictures, profuse vomiting or any of the other common problems post-operative patients face.

But my luck, it seems, has limits. And about a month ago, it ran out.
I woke up Jan. 23 like any other day, except I had some abdominal pain. I dismissed it, and made myself some peppermint tea to soothe me. By the time I got to work, though, the pain had increased. Every time I took a drink, I’d feel cramping low in my stomach.
Deciding it must be the stomach flu, I sipped protein drinks throughout the day and figured I’d let it pass.

Something serious
By 8 p.m., I was doubled over in pain. I wasn’t at home, though. I was on a business trip in the Santa Cruz Mountains. So I was alone in a rural cabin and determined to stick it out.
I was up most of the night, fighting both pain and nausea.

I called in sick Thursday and dozed most of the day. I seemed to do OK lying on my right side, and the pain would come and go, allowing me to sleep between spasms. On a scale of 1 to 10, the pain varied from a 7 to 10. I couldn’t get any water down, and I had uncontrollable belching.

By Thursday evening, I could no longer walk and had taken to crawling.
In the previous 24 hours, I had only consumed four ounces of water. Looking at the veins bulging in my chest and upper arms, I realized I had become dehydrated. On top of that, my stomach was distended and felt as if it were in flames.

Finally, I let my husband and best friend drive to the mountains to get me so I could see my local doctor the next day. It took them a few hours to reach me, and my condition continued to worsen. One look in my best friend’s eyes when she saw me told me I looked as bad as I felt. They packed my things while I laid in the bed, barely able to speak without sending myself into spasms of pain.

To get to the car, I had to bend at a 90-degree angle and shuffle the few yards outside. My husband asked why I was walking like his osteoporitic grandmother.

"This is the only way I can walk," I mumbled.

The ride to Tracy was miserable. Instead of going home as planned, we went straight to the hospital. Addressing my dehydration was the first priority. It took three nurses to get an IV in my arm. After that, I was led to radiology for a CT scan. Having to lay flat, even for 10 seconds, was the most excruciating experience of my life.

Afterward, I was hooked up to a bag of fluids and dilaudid, a painkiller 25 percent stronger than morphine. It didn’t do a lot for the pain but it allowed me to sleep.

The diagnosis
The CT scan showed I had a kink in my intestines. I was so happy to have a diagnosis that I didn’t fully process what that meant. I was admitted into the hospital for the night and scheduled to see a surgeon the next day.

After talking with the surgeon, it became clear that I would need a specialist. Unfortunately, there are no bariatric surgeons in Tracy. Finally it dawned on me that Dr. Prithvi Legha, who performed my gastric bypass, was now in private practice in the Bay Area. I had the surgeon contact him for advice.

Everything happened so fast from that point that there wasn’t even time to contact family.

I was transferred to El Camino Hospital in Mountain View the evening of Jan. 25. I didn’t know it at the time, but I was going on three days with an obstructed bowel — a dangerous problem.

Emergency surgery
I arrived at the hospital via ambulance at 9:30 p.m. Dr. Legha was already there and told me his assumption was that I had a bowel obstruction and at least one internal hernia. In laymen’s terms, my intestines had tangled into a gigantic knot and then started to twist inside out. Surgery was the only answer.

"I’m going to try to go in laparoscopically," Dr. Legha told me, "but I think you’re too far gone. I may have to open you up."

I nodded and told him to do what he had to do.

"When are we going to do this?" I asked, thinking I’d be scheduled for surgery the next morning.

Instead, he said, "now," and with that, I was wheeled into the operating room. I hadn’t even been at the hospital 30 minutes.

During the three-hour operation, Dr. Legha first tried a lap procedure, puncturing my abdomen six times. However, my bowels were so swollen and inflamed, he was afraid they would fray and break open. He cut me about five inches down the middle. He discovered two intestinal hernias in addition to the bowel obstruction. My intestines were purple from lack of blood. But I was lucky. As soon as the knot was untangled, they pinked up. I had no infection, no tissue death.

Dr. Legha is not one to mince words. He has let me know numerous times in the past month how close I was to death. Another 12 hours, and somebody at the Tracy Press would have had to write my obituary.

The road to recovery
This is one of the toughest surgeries to recover from. Not only are there incisions to heal, but the intestines must be retrained. It seems they forget to do their job after being shut down for a few days.

I was in the hospital about a week. I had nothing by mouth the first five days, but I wasn’t complaining. The thought of eating at that time seemed an impossible feat. Once it became apparent that my intestines were still asleep on the job, I was given intravenous nutrition to preserve my muscle mass and body weight. I was released from the hospital after moving from clear liquids to pureed food with little problem.

A month later, I’m back at work but still recovering. I’m slowly introducing solid food into my diet, and my body is learning to process it all. Earlier this week, I had to go home early one day after my intestines protested the chicken I had for lunch.

I tire easily, and I struggle with dizzy spells caused by low blood sugar. I’m eating between 6 and 9 ounces of food per day, not nearly enough to fuel my body. At Dr. Legha’s suggestion, I’m trying to consume most of my required protein through supplements. This will prevent my muscles from cannibalizing themselves, and it also keeps the dizzy spells at bay.

The future
This experience has taught me a variety of lessons, many of which I’ll share in upcoming columns. But for now, my focus is on building my strength and improving my health. Can’t expect much more than that.