The Darker Side of Surgery
Last Tuesday, my dad got WLS. (I know, what could be MORE apropos then WLS on FAT Tuesday???)
He and I had several discussions about surgery, but he made the decision to go for it on his own. I flew back to my hometown Monday night to be with him. I was more nervous about his surgery than mine. Although he's a "lightweight"--he was maybe 120 pounds overweight for his height, and his surgeon required him to lose 20 pounds pre-surgery, so he has 80-100 pounds left to lose to be at a "normal BMI"--he is older (not OLD, he's only 51, just older), he has a couple of co-morbs (sleep apnea and high blood pressure, with a history of heart disease and diabetes in the immediate family), so I just wanted everything to go ok.
We got to the hospital at 9am on Tuesday and waited through the pre-surgery process until about 11:30 when the anesthetist came in and started doing his thing. His surgeon, who has performed 1300 RNY's, told me he'd be about an hour and fifteen minutes in surgery then 1-2 in recovery (it's lap RNY).
At about 2pm, I started freaking out--it had been at LEAST two hours since he'd been wheeled into surgery--what was going on. I started tearing up in the waiting room, wondering what was going on, and KNOWING first hand what the statistics are for RNY (.5% of patients die during RNY, typically because of stomach leaks, blood clots, or as a result of co-morb risk factors--1 out of 200 patients isn't bad, especially when you consider that joint replacement surgery has a 2-3% fatality rate, but if your loved one is the unlucky "one", than the statistics to mean a damn thing). I talked to the waiting room volunteer, who called the nurse, who told me all was well.
About 15 minutes later, the surgeon came out and told me that he put my Dad in the top ten most difficult (anatomically speaking) surgeries he's had to perform (out of 1,300+). The reason? My dad had a twisted stomach, where the "back" of his stomach was really in the front. This made finding the right place to dissect the stomach difficult as well as correctly connecting the intestines (which were also out of place to accommodate the twisted stomach). The surgeon didn't think that this anatomical difference would affect the success of the surgery in terms of weight loss, it just made the surgical process more lengthy as they had to untangle his organs before they could do their thing.
Everything else went well in the hospital--he had good pain management, and he was discharged the following afternoon. We spent Wednesday and Thursday at home. Thursday night, he woke up with a sharp pain in his calf, which he walked off. When he woke up the following morning, the pain was still there, so he called the Dr. They were immediately concerned about a possible blood clot, so he and I drove into town to get him to the Imaging center for an ultrasound.
The ultrasound picked up a "partially occluded" blood clot in his popliteal vein (which runs from your calf behind your knee into your thigh). This sent us directly from the Imagining Center to the hospital, where he was admitted, put on immediate bed rest and given blood thinners. Blood thinners don't actually get rid of the existing clot, they just reduce the chances of more clots forming as well as help the existing clot adhere to the vein wall, allowing the bodies natural immune system to break up the clot on its own. (Typically, remember, clotting is a good thing--it's what stops a wound from bleeding continuously, so the body has a well formed cycle of clotting, healing, and breaking down the clot).
Now, if you are an astute reader, you'll recall my stats from a few paragraphs ago where I said .5% of RNY patients die from leaks, BLOOD CLOTS, and co-morb risks. It was (and is) so scary to have my Dad all of a sudden be in one of the three categories where fatalities happen. Looking at my Dad in the hospital bed and thinking about this clot traveling into his lung (which is a recipe for heart attack and stroke at a minimum, and death at it's worst), I was really mad at this surgery. Because is having a Dad who is 80 pounds lighter worth the risk to his life? NEVER. EVER. NEVER.
After I left the hospital that night, I went and saw the movie Eight Below (which I recommend) and spent about half the movie just sobbing. While it was a touching story, I'm pretty sure it wasn't the plight of the left-behind-sled dogs that had me so choked up.
On Saturday, we had a serious chat with one of the Doctors about putting in a vena cava filter--a metal mesh "umbrella" that is inserted into the femoral vein through a catheter threaded up from the groin whose purpose is to catch blood clots before they reach the lungs while allowing regular blood cells to pass by unimpeded. Many surgeons insert filters prior to surgery for those people with a higher risk for clotting (diabetes patients, for example). There are risks with the filter, including that the filter can irritate the vein and cause! clotting. The doctor told us that they would not normally put in a filter for someone who is already receiving treatment. The front line treatment for Deep Vein Thrombosis (DVT) (which is the medical term for a clot in your leg) is blood thinners in the form of a fast acting thinner like heparin (which must be administered by IV in the hospital) or Lovomax(a self-administered subcutaneous (meaning under the skin) shot given twice a day) along with Coumadin (also known as warfarin). Coumadin is a pill form blood thinner that is given for 3-6 months after a blood clot is discovered, but it takes 3-5 days to build up in your system, so folks with a blood clot need the Heparin/Lovamax therapy until the Coumadin starts working (the doctors call this being at a "therapeutic" level). The big difference between the "normal" medical protocol for DVT and what they were suggesting for my Dad is obesity, which creates a higher risk factor for clotting and for fatal complications from DVT. In an effort to be overly cautious, they were considered putting in a filter on top of the medicinal therapy.
As a lawyer, I've learned to be an analytical, aggressive thinker and speaker and the discussion with the doctor on Saturday night was not unlike a cross-examination. At one point, the doctor stopped me and asked me what my medical experience was. At first, I thought he was trying to put me in my place (I'm the doctor with the education and training, why are you arguing with an expert kinda thing), but really it was because he was impressed with the amount of knowledge I had on the topics of RNY and DVT (it's amazing what one can learn given an internet connection and some decent research skills). Through other medical experiences, I've come to realize how important it is to be a militant patient advocate for the ones you love. Doctors do have training and experience, but they are NOT omnipotent. After going through law school, people like to assume that I can answer any legal question they can think up, but really lawyers have very little practical legal skills after law school--we just have a foundation in legal theory and good analytical thinking skills and a voracious appetite for research. Legal skill comes with practical experience solving the unique issues of clients, and usually lawyers only practice in a very small fraction of the law and could only give a cursory analysis of legal matters outside their expertise. I think Doctors are the same way--they specialize, so they know their area of medicine as well as can be expected for a continually changing science. But, they don't know everything about every part of the body, and I believe that NOTHING can substitute for a self-aware patient, who intuitively knows when something is "not right" in their body. One example of this--I've always had some difficulty with my iron levels--I usually test just at the lowest "normal" mark for iron, and have had some of the symptoms of anemia. Every time I start feeling really sluggish and light-headed for a period of a few days or more, I go into my doctor, who orders a blood test, which invariably comes back as "normal". "Normal" iron counts are a patient average, but I know that if I am the bottom end of the "normal" spectrum, I feel terrible. So, regardless of what "normal" is according to my doctor and medical protocol, I KNOW that I need to be up in the top end of normal for iron in order to eliminate anemic symptoms.
Ok, back to my Dad. After much discussion about the pros and cons of placing a filter, we decided to wait for the bariatric surgeon's opinion (the doctors treating my dad were from his primary care practice group, not the bariatric practice group). The surgeon was coming in Sunday morning for rounds. After the doctor left on Saturday, we got out my computer and did another few hours of research on blood clot therapies, obese risk factors, and statistics about DVT. At the end of the night (and after a few tears were shed by my stepmom), we (me, my dad, my stepmom) decided that the filter didn't seem like it was worth the risks.
I went home to sleep and drove back to the hospital, arriving at 7:50am in anticipation of 8am rounds by the surgeon. Before the surgeon arrived, I explained to my stepmom and Dad my small change of heart. I had thought about it overnight and thought how terrible would we feel if the worst DID happen and we hadn't agreed to the filter? It would be horrible to think there was something else we could have done to prevent a pulmonary embolism but we didn't do it. I suggested that before we gave the surgeon a decision, we ask him to give his opinion on the filter and ask more questions.
When the surgeon arrived, I think the three of us looked piranhas watching an unsuspecting tourist dip a toe into the river--we were rabidly ready for his opinion and had a gauntlet of questions for him to answer. The bariatric surgeon said that if my dad had presented to him on Friday morning (instead of the PCP doctors), he would have immediately recommended a filter, out of caution. He explained that the bariatric practice group didn't have an empirical data or medical studies, but in their experience operating on obese patients, blood clots are a cause of serious alarm and the more cautious they can be, the better. The surgeon had one patient die of a blood clot, and one experience serious complications (which can include loss of limb, heart attack, and stroke) from clots. He never wanted to lose another patient to blood clots, if possible, so he would have advocated the extra measure despite the risks (98% of filter insertions go well and are successful, but there are complication risks associated with placing the filter in a major vein, as well as risks of irritating the vein, which can cause clotting, leading to the very pulmonary embolism you are trying to prevent). However, after my Dad had been on 2.5 days of blood thinners, he felt the prophylactic benefit of the filter was outweighed by the risks of bleeding during the insertion--uncontrolled bleeding in a main vein/artery can cause a patient to lose 80%+ of their blood in a matter of minutes, which is pretty much fatal.
That additional bit of information really cemented the decision to reject inserting the filter. The surgeon thought my dad would have another day or two in the hospital on bed rest (bed rest is because they don't want the clot to travel, so they don't want the patient to be moving/walking/using the leg muscles, all of which could dislodge the clot). Although bed rest sucks, it's better than death, eh?
An hour or two later, the pharmacist came in and told Dad that he could switch off heparin (IV-administered) to lovomax (injection-administered), which would allow him to go home on Sunday (the same day), and do his day or two of bed rest from home.
He's now home and has an appointment at the lab today to check his blood levels (blood thinners are a finicky medicine and require pretty frequent monitoring to ensure that the blood is goldilocks--not too thin, not too "thick", but just thin enough).
After a couple of days on bed rest, they want him to start slowing being active. The weird catch-22 about blood clots is once you have them, they want you to stop all activity to avoided dislodging the clot and it becoming a pulmonary embolism (lung clot), but in order to avoid more clotting, you need to be active, so your blood circulates more and doesn't rest anywhere forming MORE clots.
Dad just wants to get back to what I'm calling "new normal." New normal includes still being on the liquid RNY diet for another week or so, 6 weeks of no lifting, and 6 months of blood thinners (which means being careful to not get cuts or bruises, which will not clot as well).
The doctors say it'll take up to a month for the clot to dissolve (but they don't normal re-ultrasound and check, which is just crazy to me--I'd want to check and see for sure!). Dad's definitely out of the woods for now, but I won't feel like he's really in the clear until we get past the next month with no more complications or issues.
This whole experience really hit home how serious this surgery is. Even when you feel like the risk is low and it is a risk you are willing to take, it's hard to remember that you are risking yourself on behalf of all of your family and friends as well. Your risk-taking can cause THEM loss--and believe me when I say that they would rather have you alive and fat then dead and potentially thin.
I still think this surgery is an excellent tool and I would do it again, if I had to choose, but I hope that everyone who is making the decision to have surgery is really soul-searching before making a decision. It should NEVER been seen as an "easy" way to lose weight, first because there are so many more risks to this surgery then diet and exercise alone, and second, because even with surgery, it isn't a walk in the park (just ask me, the girl who had chips for dinner last night!!)
He and I had several discussions about surgery, but he made the decision to go for it on his own. I flew back to my hometown Monday night to be with him. I was more nervous about his surgery than mine. Although he's a "lightweight"--he was maybe 120 pounds overweight for his height, and his surgeon required him to lose 20 pounds pre-surgery, so he has 80-100 pounds left to lose to be at a "normal BMI"--he is older (not OLD, he's only 51, just older), he has a couple of co-morbs (sleep apnea and high blood pressure, with a history of heart disease and diabetes in the immediate family), so I just wanted everything to go ok.
We got to the hospital at 9am on Tuesday and waited through the pre-surgery process until about 11:30 when the anesthetist came in and started doing his thing. His surgeon, who has performed 1300 RNY's, told me he'd be about an hour and fifteen minutes in surgery then 1-2 in recovery (it's lap RNY).
At about 2pm, I started freaking out--it had been at LEAST two hours since he'd been wheeled into surgery--what was going on. I started tearing up in the waiting room, wondering what was going on, and KNOWING first hand what the statistics are for RNY (.5% of patients die during RNY, typically because of stomach leaks, blood clots, or as a result of co-morb risk factors--1 out of 200 patients isn't bad, especially when you consider that joint replacement surgery has a 2-3% fatality rate, but if your loved one is the unlucky "one", than the statistics to mean a damn thing). I talked to the waiting room volunteer, who called the nurse, who told me all was well.
About 15 minutes later, the surgeon came out and told me that he put my Dad in the top ten most difficult (anatomically speaking) surgeries he's had to perform (out of 1,300+). The reason? My dad had a twisted stomach, where the "back" of his stomach was really in the front. This made finding the right place to dissect the stomach difficult as well as correctly connecting the intestines (which were also out of place to accommodate the twisted stomach). The surgeon didn't think that this anatomical difference would affect the success of the surgery in terms of weight loss, it just made the surgical process more lengthy as they had to untangle his organs before they could do their thing.
Everything else went well in the hospital--he had good pain management, and he was discharged the following afternoon. We spent Wednesday and Thursday at home. Thursday night, he woke up with a sharp pain in his calf, which he walked off. When he woke up the following morning, the pain was still there, so he called the Dr. They were immediately concerned about a possible blood clot, so he and I drove into town to get him to the Imaging center for an ultrasound.
The ultrasound picked up a "partially occluded" blood clot in his popliteal vein (which runs from your calf behind your knee into your thigh). This sent us directly from the Imagining Center to the hospital, where he was admitted, put on immediate bed rest and given blood thinners. Blood thinners don't actually get rid of the existing clot, they just reduce the chances of more clots forming as well as help the existing clot adhere to the vein wall, allowing the bodies natural immune system to break up the clot on its own. (Typically, remember, clotting is a good thing--it's what stops a wound from bleeding continuously, so the body has a well formed cycle of clotting, healing, and breaking down the clot).
Now, if you are an astute reader, you'll recall my stats from a few paragraphs ago where I said .5% of RNY patients die from leaks, BLOOD CLOTS, and co-morb risks. It was (and is) so scary to have my Dad all of a sudden be in one of the three categories where fatalities happen. Looking at my Dad in the hospital bed and thinking about this clot traveling into his lung (which is a recipe for heart attack and stroke at a minimum, and death at it's worst), I was really mad at this surgery. Because is having a Dad who is 80 pounds lighter worth the risk to his life? NEVER. EVER. NEVER.
After I left the hospital that night, I went and saw the movie Eight Below (which I recommend) and spent about half the movie just sobbing. While it was a touching story, I'm pretty sure it wasn't the plight of the left-behind-sled dogs that had me so choked up.
On Saturday, we had a serious chat with one of the Doctors about putting in a vena cava filter--a metal mesh "umbrella" that is inserted into the femoral vein through a catheter threaded up from the groin whose purpose is to catch blood clots before they reach the lungs while allowing regular blood cells to pass by unimpeded. Many surgeons insert filters prior to surgery for those people with a higher risk for clotting (diabetes patients, for example). There are risks with the filter, including that the filter can irritate the vein and cause! clotting. The doctor told us that they would not normally put in a filter for someone who is already receiving treatment. The front line treatment for Deep Vein Thrombosis (DVT) (which is the medical term for a clot in your leg) is blood thinners in the form of a fast acting thinner like heparin (which must be administered by IV in the hospital) or Lovomax(a self-administered subcutaneous (meaning under the skin) shot given twice a day) along with Coumadin (also known as warfarin). Coumadin is a pill form blood thinner that is given for 3-6 months after a blood clot is discovered, but it takes 3-5 days to build up in your system, so folks with a blood clot need the Heparin/Lovamax therapy until the Coumadin starts working (the doctors call this being at a "therapeutic" level). The big difference between the "normal" medical protocol for DVT and what they were suggesting for my Dad is obesity, which creates a higher risk factor for clotting and for fatal complications from DVT. In an effort to be overly cautious, they were considered putting in a filter on top of the medicinal therapy.
As a lawyer, I've learned to be an analytical, aggressive thinker and speaker and the discussion with the doctor on Saturday night was not unlike a cross-examination. At one point, the doctor stopped me and asked me what my medical experience was. At first, I thought he was trying to put me in my place (I'm the doctor with the education and training, why are you arguing with an expert kinda thing), but really it was because he was impressed with the amount of knowledge I had on the topics of RNY and DVT (it's amazing what one can learn given an internet connection and some decent research skills). Through other medical experiences, I've come to realize how important it is to be a militant patient advocate for the ones you love. Doctors do have training and experience, but they are NOT omnipotent. After going through law school, people like to assume that I can answer any legal question they can think up, but really lawyers have very little practical legal skills after law school--we just have a foundation in legal theory and good analytical thinking skills and a voracious appetite for research. Legal skill comes with practical experience solving the unique issues of clients, and usually lawyers only practice in a very small fraction of the law and could only give a cursory analysis of legal matters outside their expertise. I think Doctors are the same way--they specialize, so they know their area of medicine as well as can be expected for a continually changing science. But, they don't know everything about every part of the body, and I believe that NOTHING can substitute for a self-aware patient, who intuitively knows when something is "not right" in their body. One example of this--I've always had some difficulty with my iron levels--I usually test just at the lowest "normal" mark for iron, and have had some of the symptoms of anemia. Every time I start feeling really sluggish and light-headed for a period of a few days or more, I go into my doctor, who orders a blood test, which invariably comes back as "normal". "Normal" iron counts are a patient average, but I know that if I am the bottom end of the "normal" spectrum, I feel terrible. So, regardless of what "normal" is according to my doctor and medical protocol, I KNOW that I need to be up in the top end of normal for iron in order to eliminate anemic symptoms.
Ok, back to my Dad. After much discussion about the pros and cons of placing a filter, we decided to wait for the bariatric surgeon's opinion (the doctors treating my dad were from his primary care practice group, not the bariatric practice group). The surgeon was coming in Sunday morning for rounds. After the doctor left on Saturday, we got out my computer and did another few hours of research on blood clot therapies, obese risk factors, and statistics about DVT. At the end of the night (and after a few tears were shed by my stepmom), we (me, my dad, my stepmom) decided that the filter didn't seem like it was worth the risks.
I went home to sleep and drove back to the hospital, arriving at 7:50am in anticipation of 8am rounds by the surgeon. Before the surgeon arrived, I explained to my stepmom and Dad my small change of heart. I had thought about it overnight and thought how terrible would we feel if the worst DID happen and we hadn't agreed to the filter? It would be horrible to think there was something else we could have done to prevent a pulmonary embolism but we didn't do it. I suggested that before we gave the surgeon a decision, we ask him to give his opinion on the filter and ask more questions.
When the surgeon arrived, I think the three of us looked piranhas watching an unsuspecting tourist dip a toe into the river--we were rabidly ready for his opinion and had a gauntlet of questions for him to answer. The bariatric surgeon said that if my dad had presented to him on Friday morning (instead of the PCP doctors), he would have immediately recommended a filter, out of caution. He explained that the bariatric practice group didn't have an empirical data or medical studies, but in their experience operating on obese patients, blood clots are a cause of serious alarm and the more cautious they can be, the better. The surgeon had one patient die of a blood clot, and one experience serious complications (which can include loss of limb, heart attack, and stroke) from clots. He never wanted to lose another patient to blood clots, if possible, so he would have advocated the extra measure despite the risks (98% of filter insertions go well and are successful, but there are complication risks associated with placing the filter in a major vein, as well as risks of irritating the vein, which can cause clotting, leading to the very pulmonary embolism you are trying to prevent). However, after my Dad had been on 2.5 days of blood thinners, he felt the prophylactic benefit of the filter was outweighed by the risks of bleeding during the insertion--uncontrolled bleeding in a main vein/artery can cause a patient to lose 80%+ of their blood in a matter of minutes, which is pretty much fatal.
That additional bit of information really cemented the decision to reject inserting the filter. The surgeon thought my dad would have another day or two in the hospital on bed rest (bed rest is because they don't want the clot to travel, so they don't want the patient to be moving/walking/using the leg muscles, all of which could dislodge the clot). Although bed rest sucks, it's better than death, eh?
An hour or two later, the pharmacist came in and told Dad that he could switch off heparin (IV-administered) to lovomax (injection-administered), which would allow him to go home on Sunday (the same day), and do his day or two of bed rest from home.
He's now home and has an appointment at the lab today to check his blood levels (blood thinners are a finicky medicine and require pretty frequent monitoring to ensure that the blood is goldilocks--not too thin, not too "thick", but just thin enough).
After a couple of days on bed rest, they want him to start slowing being active. The weird catch-22 about blood clots is once you have them, they want you to stop all activity to avoided dislodging the clot and it becoming a pulmonary embolism (lung clot), but in order to avoid more clotting, you need to be active, so your blood circulates more and doesn't rest anywhere forming MORE clots.
Dad just wants to get back to what I'm calling "new normal." New normal includes still being on the liquid RNY diet for another week or so, 6 weeks of no lifting, and 6 months of blood thinners (which means being careful to not get cuts or bruises, which will not clot as well).
The doctors say it'll take up to a month for the clot to dissolve (but they don't normal re-ultrasound and check, which is just crazy to me--I'd want to check and see for sure!). Dad's definitely out of the woods for now, but I won't feel like he's really in the clear until we get past the next month with no more complications or issues.
This whole experience really hit home how serious this surgery is. Even when you feel like the risk is low and it is a risk you are willing to take, it's hard to remember that you are risking yourself on behalf of all of your family and friends as well. Your risk-taking can cause THEM loss--and believe me when I say that they would rather have you alive and fat then dead and potentially thin.
I still think this surgery is an excellent tool and I would do it again, if I had to choose, but I hope that everyone who is making the decision to have surgery is really soul-searching before making a decision. It should NEVER been seen as an "easy" way to lose weight, first because there are so many more risks to this surgery then diet and exercise alone, and second, because even with surgery, it isn't a walk in the park (just ask me, the girl who had chips for dinner last night!!)
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4:40 AM
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