May
04

Farewell, My Sweet(s)

First, the good news! I’m down 11 pounds since surgery and 32 overall! Woot woot! Recovery continues to go well overall and I’ve been lucky enough to avoid complications (knock on wood). I’m taking it one day at a time and letting myself move slowly.

Now, the less-fun news…

This is hard as shit.

Not that I was kidding myself – I knew it would be a long road and I’ve barely gotten started. But the full liquid diet is exhausting. It literally feels like a full time job to sit there and time myself while I sip fluids like a baby bird and try my damndest to squeeze in as much protein as I can each hour. My caloric intake is so low that I am tired and weak, although I’ll be damned if I let myself get dehydrated too.

My mom was here for a blessed week and went to work making delicious creamed soups packed with veggies. We bought some unflavored whey protein powder and started adding that to our soups as well, which has helped. My aunt had the genius idea to freeze the soup in ice cube trays, so our freezer is stocked with ice cube sized portions of soup (two cubes = two ounces=one serving).

Exhibit A

Exhibit A

 

There is enough variety here to keep things interesting, but I am so sick and tired of liquids.

One thing that has amazed me is how much my taste buds and food aversions have changed since surgery. For the first several days, nothing really tasted good but nothing tasted bad either. I had zero cravings and no sense of hunger. Slowly (very slowly), certain foods are starting to sound good again. Steve had a spoonful of almond butter the other day and when he leaned over to kiss me good morning, I wanted to eat his face off. The other night he was as sick of soups as I was, so he ordered takeout from our favorite pan-Asian restaurant and brought me home some miso broth (I strained out the solids). That might have been the most delicious thing I will ever put in my mouth (it’s all relative, people).

And my sweet tooth? Gone. It was starting to dissipate even before surgery, but it has officially flown the coop. Part of the problem is that a lot of artificial protein sources are made to be sweet in order to be supposedly more palatable. But they can’t use sugar, so they use sugar substitutes, which are absolutely cloying. I want none of it.

This does make getting my protein a challenge. All of the shake recipes I pinned before surgery now make me want to vomit. I’m trying to use real fruit and plain yogurt as much as I can to cut, rather than enhance, the sweetness of the protein powders. I tried 100% fruit juice today and almost gagged. And sugar-free Crystal Light? Just give me plain water, please (room temperature too – I used to love ice-cold water but now it makes my throat seize up). You better believe that once I can start eating actual food again, I’ll be getting my protein from eggs, low-fat dairy, lentils, quinoa and seafood/lean meats. No more mile-long ingredient lists for me!

I’m trying to take consolation in the fact that I only have four more days before I can move onto pureed food. Steve is looking forward to making me the perfect poached egg…and I’m looking forward to eating it! 😉


Apr
29

All the Feelings

One of the surprises I have not been really prepared for is the gamut of emotions that I run through each day (often from minute to minute). I was warned during my preop phase that emotional ups and downs and insomnia were common after surgery. I haven’t experienced any extreme mood swings or breakdowns, but I feel as if I am constantly processing this decision and its consequences, and it is exhausting on all levels. Fortunately over the past few days the emotions have become fairly predictable, but I’m still trying to figure out where to put them all…

Usually it starts when I wake up about 3 am and can’t go back to sleep. Often thanks to a bad dream that I’ve spiked a fever or experienced any number of postop complications (being a health care provider myself is both a blessing and a curse because I have already seen the worst outcomes). My mind starts racing and it’s all over unless I take something to help me get back to sleep. I’ve also noticed some early morning headaches, especially since I have had to discontinue my prophylactic propranolol for migraines (decreased blood pressure and heart rate do not exactly help to promote circulation and healing).

Once I’m awake for the day, I’m usually pretty tired and slow to get going. I’ll sip on fluids and protein and then I’ll talk with my mom or my husband or get a supportive text or message from a friend, and I’ll start feeling pretty good about things. I’ll know that this was the right decision and that it is going to change my life for the better. At this point I’m motivated to go for a short walk or leave the house for an errand.

Sometime in the afternoon, I’ll check my fluid and protein intake levels (yes, there are apps for that), feel like I’m behind and start to get discouraged. If a family member calls to check in and wants to know exactly what procedure this was, or if I’m consulting my post-op instructions about a specific issue, it will hit me all over again…I just had 2/3 of my stomach lopped off and removed and my guts rearranged. This is permanent. This is it.

WHAT THE HELL WAS I THINKING?!?!?!?

Luckily for me, those moments of “patient’s remorse” are fleeting and not especially profound. They are usually related to underlying fears about complications or preoccupation about how to eat healthy and intentionally in a very unhealthy world. While I don’t have regrets, I think it’s important to acknowledge the doubts that accompany a significant life change. Denying that they are there can only cause me distress.

So I’m still working on all the feelings. And I imagine I will be for some time. But I’m thankful that I have this time and space to process them as they come.


Apr
27

POD #4

Today is POD (Post-Op Day) number four. So far it’s been fairly smooth sailing…hope the trend continues!

My surgeon was thrilled with how the surgery itself went. There were no complications and he felt really good about how well it seemed to go – Steve said the surgeon was just about giddy when he came out to talk to my family afterward (and I got high compliments on my liver ;-). I did have some pretty severe post-op nausea in the PACU – I don’t remember much of that period except occasionally whispering “Help me, I feel so sick”. I knew it was pretty likely to happen since it’s happened before…didn’t make it any less miserable though.

The morning after surgery I went down for an Upper GI/barium swallow to test for leaks. They gave me some nasty Gastrograffin, followed by barium, and told me to gulp it down. No leaks, but I think I drank too much because I was miserable for the rest of the day. The stuff just would not settle into my new GI tract and move through. I ended up becoming extremely nauseous again and threw up more times than I care to count. The PA looked more closely at my Upper GI results and saw a lot of inflammation (not surprisingly), so they started me on IV steroids and Protonix, plus a whopping dose of Phenergan for the nausea, and I felt 200% better when I woke up a few hours later. I was able to keep down clear liquids that evening, although in baby 1 oz quantities. I had a PCA for pain control for about the first 24 hours, then they switched me to liquid pain meds once I was cleared to swallow.

Post-op day two featured increased fluid intake with no additional nausea. My gut slowly started to wake up and start moving. So they took out my drains and sent me home!!! :-) It was so therapeutic to be in my own house, sleep in my own bed, snuggle with my hubby and puppies and start my new journey. My mom is in town for the week… it is wonderful to have a walking buddy and somebody to help me get all this fluid and protein intake sorted out. Today I graduated myself from clear liquids to full liquids, meaning I can have protein shakes again. We are also trying out some low-fat creamed soup recipes this week.

Pain-wise, I really haven’t been too bad. I’ve only taken a couple doses of the liquid narcotic since I got home…I’m a little sore but nothing overwhelming. I’ve tried to plan an outing every day with my mom to get in a good walk and to get out of the house. One trip tires me out but I honestly haven’t been too fatigued overall.

I am not hungry whatsoever and it takes a lot of effort to get in the fluids and protein I need. Right now they are more worried about my staying hydrated (dehydration is the number one complication of bariatric surgery), but increasing protein will be important for faster healing. My surgeon had mentioned that I would wake up after surgery and all of the old cravings would have disappeared…it’s so true. When we do grocery runs, every once in a while I’ll see food that I used to love, but I have no desire to taste it now or anytime in the near future. I’m hoping that I will get my enjoyment of (real) food back, just minus the cravings for processed sugars and junk. Right now I’m just glad that I can be around food without feeling deprived.

The oddest part of this whole thing so far has been the noises. Once my gut woke up, it apparently has had a lot to say. It is constantly grumbling and growling, especially at night. From what I’ve read, this is not unusual and does calm down after a while, but it distracting and kind of awkward. Here’s hoping things quiet down in that department…


Apr
21

Going Lean and Green

Although I am down to the five-shakes-a-day phase of my “liver diet”, I thought I’d share some of our favorite “lean and green” recipes that we discovered during the first two weeks. All I can say is thank goodness for the Internet (and Pinterest)! We were quite pleased with many of the dishes we made and I’ve pinned them for future reference.

The whole experience was made extra special by the fact that Steve and I cooked many of these meals together (when I wasn’t working). He is definitely the culinary master in this family, but I have always enjoyed being his sous chef, and it was really fun to try new ingredients and combinations, and enjoy the whole experience of food prep. Our version of a date night ;-). Ironically, I’ve been more interested and involved in cooking these past few weeks, mostly because I am bound and determined to make sure that I can still enjoy food (just healthier versions of it). And I’ve been watching reruns of Top Chef like it’s my job – you would think it would be torture, but somehow it’s comforting.

As for the famous shakes, my morning routine has been a splash of fresh-squeezed orange juice, a serving of frozen fruit, and vanilla protein powder, blended with a bit of ice. In the afternoons I’ll usually blend chocolate protein powder and water with a teaspoon of PB2, or vanilla protein powder and unsweetened almond/coconut milk with a teaspoon of cinnamon and a dash of vanilla extract (I swear it tastes just like a cinnamon roll). They’re actually not bad overall, I’m just tired of them.

The high protein snacks were so-so. I had to buy these soy “crisps” that had different savory flavors – the flavoring left a bit of a chalky texture, but they weren’t terrible and it was honestly nice to eat something that wasn’t sweet. The protein bars they wanted me to get were just plain nasty, so I crowd-sourced on Facebook and discovered the wonder of Quest bars. These babies helped me pull through my afternoon slumps.

Next on my culinary to-do list: research pureed options that aren’t store bought applesauce/pudding/baby food. I’ll be on liquids only for two weeks post-op and then the pureed phase begins for a week.

Any suggestions? 😉


Apr
18

The Final Countdown

Yes, I just referenced an ’80s hair band. 😛

Pardon my weird humor, it’s this damn liver diet making me loopy. Yes folks, I’m less than a week away from surgery and it ain’t pretty. As soon as I adjusted to my two shakes/two proteins/one lean and green meal regimen, it was time to switch gears again. To five (count ’em), FIVE shakes a day. Plus 64 oz of water. And that’s it. Thursday was my last bite of solid food for almost three weeks (including my post-op full liquid diet after I get home). It happened to fall on the day I had a professional nursing meeting at Ruth’s Chris, of all places. I ordered with Steve in mind, allowed myself a few delectable bites of filet mignon, and ignored my tummy’s angry howling for the rest of the meeting. The hubby and the dogs were happy at least.

I’m in hell and the only consolation is that it will all be over soon. That and I’m 15 pounds lighter (and down a pant size) from my highest weight last month. So it’s not all bad. 😉 But I don’t recommend this part of the process as a weight loss strategy. It’s wholly unpleasant.

I’m not going to say that the shakes were the worst part of this experience because I haven’t had to recover yet. But I’m not a fan. I’m foggy and exhausted and irritable all.the.time. Writing end-of-semester papers is an exercise in sheer willpower. I think the dogs are trying to hide from me. And Steve, wonderful, steadfast, loving Steve continues to take care of me because, well, he’s the best. Thank God for him.

As far as how I feel about this huge step, I have my moments of wondering what the hell I’m doing, but I know it’s the right decision. But my anxiety seems to be taking the subconscious route and last night I started having some CRAZY dreams, to the point that I woke up at 3 am and was afraid to go back to sleep. I have a prescription for benzos to get me through the night before surgery, and I’m thinking I might need to start those a few days early. Nurse Teeny needs her sleep, preferably not riddled with nightmares about my surgeon having a crisis of confidence and begging me not to go through with this. Yikes, huh?

More than anything, I just want to do this thing. Enough waiting, enough shakes (blech), enough worrying. Just get me on that table so I can keep moving forward…


Apr
16

Have You Had Your Conversation?

Good morning! Today is the 8th annual National Healthcare Decisions Day (NHDD). NHDD “exists to inspire, educate and empower the public and providers about the importance of advance care planning. NHDD is an initiative to encourage patients to express their wishes regarding healthcare and for providers and facilities to respect those wishes, whatever they may be” (source). It is an issue that I happen to be passionate about.

NHDD_logo

NHDD was started by an attorney in Virginia and went nationwide in 2008. The purpose is to focus attention on and provide information about advance care planning, and encourage folks to have conversations about their wishes with loved ones.

Steve and I made our advance directives several years ago. With surgery approaching next week, I rehashed some of the salient points with him, to make sure that if something went wrong he had my wishes at the front of his mind. Not to catastrophize, but sh*t happens and I’ve seen too many worst-case scenarios not to be prepared.

 

(Source)

ABC Breaking US News | US News Videos

Whether you’ve been intending to complete an advance directive or you’ve never heard of one, I encourage you to spend some time today and get additional information. You can even complete an advance directive online through an organization called Five Wishes if you live in one of 42 states where it is recognized. Yes, it costs $5, but I think it is worth every penny to have your wishes honored (which to me is priceless).

There are many, many resources about advance care planning, but here are some good places to start:

And please feel free to leave questions in the comments section of this post. I will do my best to get them answered!

advance_directives

 

Thank you for starting the conversation!


Apr
14

We Must Do Better

Dear Colleagues,

I have a request. And it isn’t a small one.

But it’s a crucial one.

You see, I work in an inpatient hospice unit. Inpatient hospice signifies that patients require a level of care that cannot be managed in the home setting. They must have active symptoms to qualify for inpatient care. It’s basically a “hospice ICU” in that we are constantly titrating drips and pushing meds and doing everything we can to keep our patients comfortable. We’re not trying to save lives but we’re certainly trying to make them feel better…and in a way, that’s saving lives too. It’s a busy, busy place.

I’ve been noticing that every so often (too often), I admit a patient from another facility whose condition is appalling. Not because they’re dying. Because they were made “comfort care” in a hospital two days ago and yet they arrive to us covered in defibrillator pads and EKG stickers. Because they were living in a nursing home or assisted living facility with visiting hospice care and they come to us with pressure ulcers because the staff deferred skin care to the hospice nurse who only comes once a week. Because they have been incontinent for days and sitting in their own urine to the point that their perineum is excoriated and putting in a Foley catheter to protect their skin causes excruciating pain.

I know being a nurse is exhausting. I know working on a hospital unit or nursing facility means a heavy workload and way too many patients. But I’m begging you to pay as close attention to the ones who are dying as you do to the ones you are trying to keep alive. I know the temptation is to assign your “comfort care” patients to the nurse who has the most difficult group of patients – I’ve actually heard charge nurses say out loud: “Oh they’re comfort care, so they won’t need anything. They’ll be easy and you can focus on your other patients.”

No.

The fact is that if your patient is comfort care and you are doing your job, you’ll be more busy. You’ll still be rounding on your patient regularly, remaining vigilant about any symptoms that need to be addressed.You’ll be providing compassionate care to families, acknowledging that even your worst day at work pales in comparison to their worst day ever. You’ll be advocating to providers for better pain control, or more interventions for dyspnea. You’ll be working your ass off to help your patients die with dignity and comfort.

I’m not trying to tell you how to do your job (but I kind of am). Please pay attention to those patients nearing the end of their lives. DNAR means “Do not resuscitate” – it does not mean “do not provide care”. Many of them won’t make it to inpatient hospice. They won’t be stable enough to transport, or their families may not wish to have them moved if they are actively dying, or there won’t be a hospice bed available. We all have to pitch in. We all have to provide excellent end-of-life care, no matter where we work.

We can do better. We must do better.

Thanks for hearing me out.


Apr
08

The Liver Diet

With my surgery fast approaching, last week was the start diet for my preop “liver reduction diet”. The idea behind this diet is that obese people tend to have enlarged livers due to increased glycogen storage (thanks to all those carbs) and fatty deposits. By reducing overall caloric intake (carbs especially), the goal is to shrink the liver as much as possible because it has to be moved out of the way during surgery. The bigger the liver, the higher the risk of damage. The liver diet is also intended to mentally and physically prepare you for postop eating, which is reduced in volume and calories and features frequent high-protein meals. Plus, the liver diet also tends to result in more preop weight loss, which is always helpful during recovery.

Searching for these diets online, every bariatric program’s guidelines are slightly different, but the concept is the same. Here is my surgeon’s program:

  • Weeks 1-2: Two protein shakes a day, two high protein/low carb snacks, and a “lean and green” dinner. Shoot for 64 oz of water daily. I am also allowing myself one serving of fruit a day, which I usually mix into my morning protein shake for better flavor.
  • Week 3: Five protein shakes a day. Shakes and clear liquids only the day before surgery.

Overall, this has been rough going so far. Getting used to eating such small amounts overall has left me hungry and exhausted – I feel almost flu-like. I’m sure as my stomach shrinks it will get easier, but I am so run-down. Working 12-hour shifts during this adjustment period hasn’t made it any easier, but I gotta make some money before I take unpaid time off. On the plus side, I’ve been doing this less than a week and I’m down four pounds. I know it’s not a healthy thing to do in the long-term but I am under the guidance of a physician and this is for a specific purpose. I just wish I wasn’t so darn tired…

I have been really strict about not “cheating” because I know myself and I know how easy it is to turn into a gorge session. Yesterday our manager ordered pizza for the staff working Easter and it took all I had to say no, especially when my co-workers said “just one bite” wouldn’t hurt me. Frustrating, to say the least. I’m realizing more and more how complicated my relationship with food has gotten over the years and how difficult it is to help people understand that just one bite is not just one bite for people like me.

In the process of going through this experience, we have actually found some really yummy “lean and green recipes” for dinners. The guidelines are similar to a ketogenic diet (except for the high-fat part – I’ve tried to find low-fat variations). I’ll try to put together a list of some of our favorites.

So the verdict overall? This is really tough but it’s also temporary. And I’m setting myself up for a better experience during and after surgery.


Apr
06

Weight Loss Surgery: The Preop Phase

One of the aspects of this experience that I really appreciate was how thorough the bariatric surgery preop approval process was. It made me feel confident that it wasn’t just about the $ for my surgeon. Even more importantly, it showed me that I could see this through. The number of appointments and evaluations I had to get through in the midst of school, work and clinical, was a little bit nuts. But I did it.

Did I bitch and moan along the way? Perhaps a little. 😉

Of course, part of the reason this experience was so detailed is because insurance requires it. Since this is considered an elective procedure, there are a lot of hoops to jump through to demonstrate you’re not too unhealthy to have the surgery in the first place (ironic, no?). But regardless, I feel much better about going into fairly major surgery knowing that we have prevented potential complications as much as we can.

Here is a run-down of my preop life, in calendar view:

  1. December 18, 2014: Attend an information seminar led by my practice’s case manager and one of the surgeons (the surgeon I ultimately chose to do my procedure). Learn about insurance requirements and the different types of surgery available. S comes with me and tells me he will support whatever decision I make. What a guy.
  2. January 21, 2015: Initial consult with the surgeon to talk about my options. We’re weighing SIPS versus sleeve gastrectomy. While I’m there, have labs drawn and get an ECG and chest x-ray done at the neighboring hospital. Also meet with the case manager to discuss the entire process, step-by-step.
  3. January 29, 2015: Tell my family that I’m planning to undergo weight loss surgery. Get nothing but love in return. I am a lucky lady.
  4. February 4, 2015: Seven-day food diary review with the physician assistant in the office. We discuss some of the changes she recommends I make now. Also find out during this visit that I had an abnormal ECG, which means I’ll have to get a cardiologist to clear me before I can be approved. Rats.
  5. February 12, 2015: Evaluations with the in-house nutritionist to talk about the pre-op and post-op diet requirements, and with a psychologist to make sure I can cope with the lifestyles changes I’m going to face. Also fill out two psych tests to make sure I’m not (too) crazy. 😉 Accomplish both evaluations in one day. Fun.
  6. February 18, 2015: Initial evaluation with cardiologist. He thinks the ECG was probably due to “low voltage given [my] body habitus”. In other words, I was too large to get a good signal. But just to be safe, we schedule a stress test and echo for later this month. This is also supposed to be the night I have my sleep study, but then it starts to snow and all of North Carolina goes into lockdown mode. Sleep study is rescheduled.
  7. March 4, 2015: Long-awaited sleep study to determine if I have obstructive sleep apnea (OSA). I’d been diagnosed with mild OSA years before but never got a CPAP because insurance wouldn’t cover it at the time. I have a feeling it’s worse these days.
  8. March 12, 2015: Undergo EGD (aka esophagogastroduodenoscopy…say that five times fast) with my surgeon. Nothing too scary  in there. I’m cleared for surgery from a GI standpoint.
  9. March 13, 2015: All required testing for insurance purposes is done. Case manager submits me to insurance for pre-approval and tells me it will take about 14 business days.
  10. March 17, 2015: Stress test and echo. Cardiologist says everything looks good, except for my markedly reduced exercise capacity for a woman my age. No sh*t. But I get my cardiac clearance.
  11. March 18, 2015: Sleep study #2. Sleep apnea was confirmed (much more severe this time around), so now I come back to be fitted for a CPAP and figure out what settings I will need at home. Find out I have to meet with the sleep center medical director (who also happens to be my surgeon) to review the results before I can be scheduled for surgery. He is booked for two weeks. Start to panic that I won’t be able to schedule surgery during the very narrow window I have in between semesters to get through it and start to recover. Want to cry. Sleep center manager sees my distress and fights for me to get an appointment by the weekend.
  12. March 19, 2015: Receive notification that insurance has approved my surgery! What a relief!
  13. March 21, 2015: Early Saturday appointment with sleep center director/surgeon to review my sleep study results. He knows I’m pressed for time as well and his medical assistant flips my visit to a results review – to go over all of my diagnostic testing at once. It’s the last step before I can be scheduled. I love these people. Before I leave he checks his calendar and gives me a date: April 23. I could kiss him.
  14. March 23, 2015: Get a phone call from the surgery scheduler that I am officially on the books for 4/23. They email me preop instructions and we pick a date for my pre-op appointment with anesthesia. One month to go.

I’m exhausted just re-creating this list! Let’s just say I’ve already met my out-of-pocket maximum for the year, and I haven’t even had the surgery yet. Lots of ups and downs over the past few months, but when all is said and done I’m glad they were so thorough.

Next up: the dreaded pre-op “liver diet”. It’s only temporary, right?


Apr
03

About My Choice

By now you’ve had a few days to digest my big news (pardon the pun). You may have mixed feelings about it. Trust me, I’ve been preparing for this experience for four months now, and I have my moments.

If you are curious, the exact procedure I will be undergoing is called a SIPS (stomach intestinal pylorus-sparing surgery). It is a fairly new surgery that pairs two procedures: the vertical sleeve gastrectomy and a modified, less technically-complicated version of the duodenal switch. A version of this procedure was first trialed in Spain, with amazing results and few complications. It is currently offered at five centers across the U.S. and thus far outcomes have been phenomenal. By combining both restrictive and malabsorptive processes (but avoiding some of the malabsorptive issues common with a gastric bypass), it is being touted by some as the future of bariatric surgery. My surgeon has been doing these since last year and has been really pleased with the results. Granted, it is new-ish (first performed in 2007), so long-term outcomes are not yet available.

Check out this video for more detail (and somewhat gross surgical footage, for those of you who enjoy that sort of thing ;-):

I’ll post more about the preop process I had to undergo, as well as some of the postop requirements, in the next few weeks leading up to surgery. Rest assured that this will not become a personal diary about my weight loss journey. But I also believe that this experience is an important part of my overall journey. And being transparent about the struggles as just as important as celebrating the victories.

In the meantime, tell me what you think! Do you know anyone who has undergone weight loss surgery? How did it go? What are your thoughts on this process? I want to hear from you.

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