Monthly Archives: August 2016

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kitty_napThe radio silence has been due to my having surgery last week and being in recovery mode since. The short version of this article is as follows: surgery is never fun, it's weird not feeling hungry, and life is good. If you want the details, keep reading. Otherwise, have an excellent day, see you next time.

The surgery went very well. I have a history of having severe nausea after anesthesia, and considering it's the #1 post-op complaint about bariatric surgery, I was a bit worried. But my anesthesiologist gave me a drug beforehand, plus a scopolamine (motion sickness) patch, and gave me IV Zofran during the procedure. Whatever she knocked me out with caused me to lose a chunk of time, I don't even recall being moved from the pre-op area to the surgical suite, nor being in post-op recovery at all. I had absolutely zero nausea. I had filled a couple of prescriptions for dealing with it at home but haven't opened them up at all.

My post-operative pain was there, but it wasn't even comparable with the pain after my knee reconstruction. It was enough I couldn't ignore it and limited some movement, but it wasn't unbearable. Which is good, because I found out that Dilaudid doesn't do jack for me. If the pain had been much worse, I'd have asked to try morphine instead, but it was already lessening by Day 2. Tramadol took the edge off, so I didn't ask for Norco. Went home Day 2 and by Day 3 my unmedicated arthritis hurt worse than my stomach. At this point, it's slighty sore when I move certain ways, and that's it.

Recovering from surgery means a lot of sleeping and laying around doing nothing. Since my arthritis is flared up, I can't really do any knitting or crafting that I would like to when forced to rest for hours on end, so I've been watching a lot of Netflix. And drinking. Water, I mean. Well, and the protein shakes. My instructions are to drink at least 48 oz of fluids and get about 60 grams of protein in, with more being better and fluids being a higher priority than the protein at least to start. I didn't meet the fluid goal until Day 5, and still haven't met the protein goal, but I've been improving every day.

When researching the surgery, almost everyone I talked to said that their appetite completely went away after the surgery, and they had to remind themselves to eat. While I really hoped that it would happen for me as well (and worried that it wouldn't) it's been a huge adjustment. I'm really not hungry. My stomach can be empty, and I know I'm physically hungry, but I just don't feel hungry or interested in food. It's not quite a food aversion (though I am getting hellishly sick of protein shakes) but just a general disinterest. I'm using timers on my phone to remind me to drink and eat because I'll get involved in something and just not think about it.

I had arranged to work from home this week because of the surgery, and it was a good call. Today is probably the first day I think I could manage the office if I had to. My department has started offering part time work from home, and my days are Tuesday and Thursday, which breaks the week up well. I was on the fence about it, but after this week I will definitely take advantage of it.

I'm already down about 13 lbs from my weight on the surgery day, so that's awesome. Of course, the journey is just beginning, but I think I'm off to a great start.

kaizen

I used to love Tony Robbins, reading his books and watching his shows. I still think he's awesome, but hadn't thought much about him until this past week. One of the things he promotes is from the Japanese concept of 'Kaizen' which in simple terms is to commit to constant improvement in whatever you're trying to achieve. Never being satisfied with your performance, and looking for little ways to improve. This really resonated with me when I was younger, and I've worked to implement this in my own life.

What really got me thinking about it this week however, was a simple blood draw. With surgery upcoming, the surgeon wants to make sure I'm healthy and all that, and it's standard to draw some blood and run a few tests to make sure the system is operating within normal parameters. No big deal. I have zero issues with needles. Back in the day, we practiced on each other in Paramedic school, and since then I've let nursing students and other people training to start IVs and draw blood to practice on me. I don't have much pain with it, even though I bruise like fruit and sometimes come away from those sessions looking like a junkie.

I preface all of this by letting you know up front that I am an easy stick. My skin is quite light, and while some veins are not visible to the eye, they are easily felt and not very deep. My veins aren't particularly prone to rolling or blowing. I also have quite a bit of experience with both blood draws and IV starts. I am fond of telling people "I used to do this bouncing down the road in an ambulance with very little light." I am not a "vein whisperer" by any means, but I'm better than average, I would say. Working in the ER as a nurse gave me opportunity to regain my skills from years ago as a Paramedic and expand on them.

Drawing blood requires a slightly different technique than starting an IV, but they are similar enough that we tend to discuss the techniques interchangeably. It's a skill to be sure, so my next comment is not intended as a denigration of the people who do it. It is not rocket science. It doesn't take dizzying intellect or some special knowledge, nor is it an unachievable skill for most people. People who are particularly good at it usually are happy to give you tips and tricks they use, and with the advent of the internet there are dozens of places to go for information including videos about improving your IV skills.

So it always surprises me a little and seriously disappoints me when medical professionals who need to draw blood or start IVs regularly just throw their hands up and say "I'm not very good at this." It reminds me of a scene from one of my favorite movies where a hunky Viking throws Antionio Banderas' character a sword, and he complains that it's too heavy to use. The Viking's response? "Grow stronger."

So my surgical intake nurse this week was very nice, and seemed to be a very competent nurse. She wasn't a new grad by any means. As a surgical intake nurse, she probably has to draw blood on a dozen people or more a shift. I could tell she wasn't terribly comfortable with the draw, so I tried to reassure her by letting her know that I'm not a hard stick. She flat out told me that she can't really feel veins at all. This floored me a bit, since you can't see the veins on most patients due to skin pigment, tattoos, scars, hair, and more. We are taught to evaluate the veins by feel. Location, direction, valves, "bounciness", and size are all things we tell from feeling the arm.

One of the large veins that is almost a default for blood draws and often for IVs is the antecubital, which is on the inside of the bend of the elbow. You know the one I mean, some of you are cringing and pulling your arm in to protect it as you read this. Mine is fine, no issues with sticking it, pretty much ever.

She missed it. Clean.

Which I should be happy about, since that means it doesn't bruise. But there's no reason for it. I was hydrated and in reasonably good health. So she moved to my forearm wherebruise she could see the vein. Long story short, she went through the vein. Which is actually quite common with people learning to do blood draws, but they usually get better. It makes for a leaky IV and blown veins if you're trying to start an IV, but it doesn't usually screw up a blood draw. So she got the blood she needed. And I got this bruise:

I'm honestly not upset with the nurse. Like I said, I routinely let people practice on me. But I am disappointed that she doesn't seem to be trying to get better, she's just accepted that she's not good at it. In her position, that means that people who are harder sticks than I am get stuck way more than they need to. She did state that if she didn't get the second try, she'd get someone else. Which is good, because it at least limits the number of sticks and bruises. However, there are people for whom even this article is painful. They have a real anxiety about needles, and it's traumatic for them to have repeated sticks. Some people are truly hard to stick, and while they're usually patient, they need people who are working to improve their skills, not people who have given up.

When I was working ER, it was a point of pride that I was pretty good at IVs. I enjoyed having people come to me for help when they were having problems. I liked passing along the tips and tricks that worked for me and seeing my cohorts improve their skills as well. When I worked with honest-to-goodness vein whisperers (and I worked with several) I watched carefully how they did things, and asked questions. I sought out internet resources to find new information about ways I could keep getting better. I would ask for help when I was outmatched by a patient's veins, because I wasn't going to turn my patient into a pincushion. But it was my goal to be the person who, if I couldn't get a line, the patient needed a sonogram placement or a surgeon to place a central line. I wouldn't be satisfied with myself until that happened.

Kaizen isn't an obsession with perfection.  It's a commitment to becoming just a little better every day.  That's a healthy approach, and one we should all embrace.

Especially if you draw blood every day.  Just sayin'.

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1345951608-rocky-no-easy-way-out-400x400I'm lucky that I haven't actually had someone say to my face "you're taking the easy way out". Mainly because I'd likely have to contact my attorney about defending me against charges of battery, and that probably gets expensive.

Or assault. I used to think I had the distinction clear in my head (assault is the threat, battery is the actual touching), but I've had people tell me that it's just assault. (But I digress.)

Right now I'm on my pre-op diet. The surgeon calls it a fast, but I do not think that word means what she thinks it means. (Any opportunity for a Princess Bride quote should not be squandered.) She has me drinking protein shakes 2-3 times during the day, and having a "healthy dinner" and can have "healthy snacks" if needed. MyFitnessPal informed me after I closed it out last night that if I continued eating like that, I'd lose 15 lbs in the next 5 weeks. Well, heck. I should just do that, then, instead of having 75% of my stomach cut out, right? I mean, isn't this really just a way to get out of having to have discipline and self control?

One of the things we've learned about dieting and maintaining weight loss is just how freaking HARD it is. Some of us are genetically programmed to put on weight easier than others. That's not an excuse, it's science. Then our bodies adjust to the new weight and fight like a cat in water to keep it on. This is what's commonly referred to as "Set Point". Our brains use a bunch of hormone signals to make us crave salty, sugary, fatty foods in order to maintain the weight the body thinks is correct. When we successfully lose weight, our metabolism lowers and our caloric intake decreases, requiring us to eat even less, all the while fighting against this tide of hormones. Food manufacturers know this, and create convenience foods that are full of the salt, sugar, and fat our bodies are screaming at us to eat. Culturally, we don't expend as much energy as our ancestors, and cram our schedules full so that eating home cooked foods is a struggle. Worse, the more weight you pack on, the worse this uphill battle gets.

Whew. And that's without even touching the emotional and mental barriers we face. Talk about the deck being stacked against you.

Yes, some people do successfully lose a lot of weight. And some of those are able to keep it off for a long time. And some of those are able to keep it off (mostly) for the rest of their life. It's possible. Possible does not mean realistic, though. It's possible for me to become a concert pianist. However, starting at the age of 46, it's really really damned unlikely. Likewise, it's possible for me to lose the 120-140 pounds I need to and keep it off without the surgery, but it's really really damned unlikely. Seriously. A 5% chance I'll keep *any* of it off past 5 years. Surgery raises that chance to somewhere between 50% and 70% depending on the study reported. Commitment to the lifestyle changes can bump either of those estimates up, certainly. The starting line is a little better at 50% or 70% than it is at 5%.

Wait a minute, didn't I just make an argument for it being the "easy way out"? Depends, I guess, on how you look at it. If I am running a race, and it's uphill, is it taking the easy way out to ditch the 50 lbs of sand someone put in my backpack? Is it taking the easy way out to buy good running shoes with good ankle support, or should I just go ahead with the 3" heeled pumps because that's what I was given? I'm choosing to equip myself better for the long haul. To me, that's smart, not cheating.

Let me talk for a minute about how "easy" this is. Once I made the decision to move forward with this, I had to schedule a string of appointments. A seminar with the weight loss surgeon. A one on one appointment with the surgeon. One with my cardiologist. Followed by a stress test with the cardiologist. One with a nutritionist. One with a psychologist to clear me for surgery. Three months of a supervised diet with monthly lectures from the doctor supervising me. Another with my primary physician to clear me for surgery. An upper endoscopy with my surgeon to check for ulcers and hiatal hernias. A follow up appointment with the surgeon about the endoscopy. Another appointment for the final preparations once insurance approved me. Pre-op testing, though I can skip the EKG since my cardiologist had to do a stress test. All totalled, I have spent almost $900 out of pocket for co-payments and co-insurance. I'll spend another $1,000 out of pocket over the next couple of months. (I'm grateful to have excellent insurance, without it I'd have to go to Mexico and it would cost me on the order of $5,000 plus travel, or some $10,000 to $15,000 to have it stateside.) That doesn't count the $1,200 I've spent so far with a therapist facing some of the food issues that would derail this process if left alone, because I'd have that expense if I tried to do this with just diet and exercise.

Now I'm on a two week "fast" and it's hard. The snack machine at my office tempts me every time I walk by to refill my water mug or mix up another powdered protein shake. The fast food restaurants taunt me as I drive by them. I want to EAT ALL THE THINGS because I'm starving, I have a headache, and I'm groggy. Oh, and I have to be off all of my PsA meds for the surgery, so I also have pain in my hands, my feet, my back, and my knees. I can't distract myself with crafts because my hands hurt. I can't take a walk because it feels like spikes in my arches. I'm on day 3 of 14, and I'm fairly miserable.

After surgery, I'll be on a full liquid diet for 1-2 weeks. Then I get to have pureed food for another week or two. Then I get to "graduate" to soft foods like eggs and tuna. It'll be 4-6 weeks before I can have "regular" food again. Even then I'll have to add foods one at a time and be very careful because my tolerances and tastes will have changed, and any given food - or too much or to fast - can make me very ill. I'll very likely be on a fairly restrictive diet for up to a year. Once my system recovers, and I'm at or near my goal weight, I'll get to add foods to my diet in a measured way. 18 months after surgery, my diet should look fairly normal, though with slightly smaller than normal portions.

Meanwhile, I'll have to get creative in order to stay clothed during this time. People report changing a size or more every week or two through this process. I should count myself lucky that it's culturally acceptable for me to wear skirts, because I forsee many months in drawstring maxi skirts. If I were a guy, this wouldn't be as easy, and that might be the first time (and likely the only time) I'll ever say that regarding fashion. Oh, and a lot of my hair might fall out.

But some will still say it's the EASY way out.

No. The EASY way out is to keep doing what I've been doing and not make any changes in my life. The EASY way out is to keep trotting out the tired and worn excuses as to why I can't do better. Not trying, THAT is the easy way out.

Anyone who is out there making changes to improve their health and life is NOT taking the easy way out. Choosing different tools to help make those changes is not taking the easy way out. Dietary changes are a valid choice. Exercise is a valid choice. Surgery is a valid choice. Medications are a valid choice. Any combination of the above and more is a valid choice. Each has risks and benefits that are unique to each person. Not one of these (or any combination of them) is the "easy way out".

So do me (and my attorney) a favor. Don't tell me I'm taking the "easy way out".

convenient-to-bring-wheyI started my 2-week pre-op diet today. 2-3 protein shakes plus a "healthy dinner" each day. Doc said I could have "healthy snacks" if I needed. She's not as strict as some surgeons about the pre-op diet, and I am grateful for that. However, I really need to try and stick to the pre-op diet. The goal of a pre-op diet is to get a little weight loss and shrink the liver, which sits in front of the stomach and has to be moved out of the way for surgery.

Honestly, this phase has scared me more than the surgery itself or the post-op diet. After the operation, it seems the vast majority of "sleevers" lose their cravings for food, and actually have to remind themselves to eat. That effect is what keeps me from worrying overmuch about the post-op diet that progresses from liquids to pureed foods to soft foods to solid foods over the course of about a month.

Before the surgery and the loss of appetite though, I worry about my ability to do this. When I try to restrict, I get incredibly fatigued and headache-y with brain fog, and find myself craving all sorts of things that aren't on the plan. Add to the stress that because of the surgery I'm off my meds which means my chronic pain level has gone up from a 3 or so to a 5-6 and I'm finding the pain causes cravings for comfort food (aka sticky pastries, chocolate, and anything else super carb-y and super sweet).

In light of this struggle, I thought I'd take Monday and Tuesday and do some "dry runs". Breakfast isn't a big thing, since I already substitute SlimFast or something like it for breakfast periodically. It's the 11am hungries that start the problems. For my "dry run" days, I ended up eating a protein bar for lunch. By about 2pm though I was hurting, starving, brain fogged, exhausted... and hit the snack machine.

Today I'm thinking positive thoughts. Drinking lots of water, and I have plenty of protein drinks standing by. I can do this... I hope.