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One surgeon to another, over patient on operating table:  "I say we just take out that squiggly green thing and see how he is tomorrow."   Beyond the Fringefan #399   

#399 BEYOND THE FRINGEFAN recently said goodbye to a son and a gallbladder in the same month. He expects to see the son again in a bit more than two years; the gallbladder, probably never again in this life. Speaking of things that ought to be excised, this is Beyond the Fringefan #399, for readers of APA-NYU Volume 8, #6 (e-APA-NYU #74) and other recipients of bile, published June 2010 as a combined production of Quick Brown Fox Press and Syscrash Consulting, both subsidiaries of Thigamajig Inc. logo. If you think he should have cut more fat out of this zine, let him know at the N.Y. Cadre ((phone(718) NY-CADRE); e-mailnycadre@alum.rpi.edu; Webhttp://www.nycadre.org). Cartoon above from Close to Home by John McPherson, 14 May 2009. All uncredited material copyright ©2010 by Marc S. Glasser. Member fwa.

COLOSSAL GALL: "I'm sure you're all aware that this week is National Gall Bladder Week, and so as sort of an educational feature at this point I thought I would acquaint you with some of the results of my recent researches into the career of the late Doctor Samuel Gall, inventor of the gall bladder, which certainly ranks as one of the more important technological advances since the invention of the joy buzzer and the dribble glass. Dr. Gall's faith in his invention was so dramatically vindicated last year, as you no doubt recall, when, for the first time in history in a nationwide poll, the gall bladder was voted among the top ten organs." —Tom Lehrer

     It started (again) for me Tuesday night, 18 May. Donna, Ethan and I had driven uptown to meet with his lady friend, who had just had her PhD bestowed on her, and her mother, who was in from California for the occasion. (Note to self: the food at Miss Mamie's Spoonbread Too is o.k., but not worth a special trip.) I went to bed and was awakened two hours later by a dull pain around my shoulder blades, which over the next couple of hours worked its way down into my gut, and a need to belch up massive quantities of gas. These symptoms were more than vaguely familiar, resembling the start of what had gotten me in mid-February and mid-March.

     I didn't sleep much more that night, but I (perhaps foolishly) went to work the next day. After an hour of intense fatigue, watching the letters slide around on the screen and the paper, I realized the futility of the effort—especially since both that night and the next were shaping up to be late nights. Fortunately, the temp agency was able to bring in a substitute for me for the rest of the day, so I subwayed to my doctor's office.

     Dr. Hegazi did the usual examinations, and said he wasn't sure yet what was wrong—he was suspecting something involving acid reflux, and he gave me a prescription for an acid reducer (similar to Pepcid). But he also took blood and urine samples for testing, and sent me for both a chest X-ray and an abdominal sonogram—surprising since I didn't think I was pregnant.

     The earliest I could schedule the X-ray and the sonogram was the next day at a lab halfway across Brooklyn (the lab nearer me offered an appointment 16 days later), so I called work and told them to keep the sub for another day. I tried with only moderate success to sleep the rest of the day and night; I didn't feel up to doing much else, other than throwing up once. (I definitely did not have a good day.)

     Thursday I made it out to the lab in Bay Ridge, where the procedures went uneventfully. (Or so I assume, never having had an abdominal sonogram before.) The technician doing the sonogram at one point expressed the opinion that it looked as though I might have a gallstone. This did not cheer me up. Of course, she was only a technician, not a doctor, but I looked up gallstones on Wikipedia when I got home. (The page was distressingly sparse on treatment details.) Once again, I didn't feel much like doing anything but sleeping the rest of the day and night; this time I was a bit more successful, managing some stretches as long as an hour in between bathroom visits. (I had no appetite, but was very thirsty the whole time. All that Gatorade had to go somewhere.) I also noticed that, though I'd had no fever when I saw the doctor on Wednesday, I was developing a slight one now (~100° F).

     Friday morning, though I still felt grossly tired, I was able to get myself out of bed, showered, dressed, and over to the subway. Emerging from the subterranean environment (virtually no cell reception), I got a call from my doctor. My white cell count was seriously high (about 20,000—normal is about half that), and he wanted to see me immediately. So I walked the remaining two blocks to work, told Sara what was going on, and immediately subwayed back to Brooklyn and Dr. Hegazi's office.

     One of the first things I asked when I got there was whether the technician's remark about gallstones was relevant (and reliable). Dr. Hegazi said that the elevated white cell count was not symptomatic of gallstones alone; it indicated a systemic infection. However, he confirmed that I had gallstones. Apparently he'd known this for a while, but hadn't done anything about it because the majority of gallstones produce no symptoms, sitting quietly in the gallbladder while bile flows around them and the patient goes about his or her business. (30% of people my age have them, he said.) It's only when they start blocking the bile ducts that they cause trouble and need to be surgically excised. But now it appeared that my gallstones were indeed causing problems, so he sent me up to the E.R. at Methodist Hospital to talk to a Dr. Taylor there. (No ambulance this time; I called a cab.)

     Before I left his office, I asked Dr. Hegazi two more questions: whether the root canal I'd had last month, which according to the dental surgeon still might be infected, might be the source of the infection; and what sort of surgery was ahead if the problem really was gallstones. His answer to the first question: "I don't know." In answer to the second question, he told me that current medical technology calls for laparoscopic cystectomy—removal of just the gallstones, not the whole gallbladder, via a "minimally invasive" procedure that nonetheless requires general anesthesia. [NOTE: Don't correct me on this; I was corrected many times the next day—see later in this story.]

     I arrived at the hospital at 12:15 pm and went to the E.R. as instructed. Though I had the name of a doctor to talk to, and a packet of papers with his name on it, I got processed like any walk-in. (I did eventually speak with Dr. Taylor, who said it didn't matter; any E.R. doctor was equally qualified to evaluate me at that point.) At typical E.R. speed, I was eventually assigned an ER bed (at about 3 pm), examined by a Dr. Cardenas, stuck with an IV tube in my left hand (about 4 pm), sent for another abdominal sonogram (not quite 5 pm), started on an IV antibiotic called Zosyn (about 6 pm), told that my gallbladder was indeed infected and that I'd shortly get to talk with a surgeon named Dr. Gardezi (7:10 pm), and told that I was being admitted and taken to room 411 in the Infill Pavilion (about 10 pm).

     Before leaving the ER I sought some water—I'd had nothing to drink in some hours (nor to eat, but I'd had no appetite in days). They wouldn't let me have any, because it was possible I might get surgery on an emergency basis, or so they told me; I don't think there was an official NPO (nothing by mouth) order in place, but there was no doctor handy who would say officially that I shouldn't be NPO, so they maintained the presumption as they brought me up to my room, and all night until about 6 am. (I felt a sense of déjà vu, as Donna had gone through some of this a couple of months earlier during her last bout of surgery.)

     I was deposited in Infill 411 about 10:40 pm. A night nurse named José introduced himself, (yet again) took my history, and took enough pity on me to bring me some ice chips. I slept fitfully over the next few hours, interrupted by another patient having a screaming fit in the hall about 2 am (he sounded kind of like Costello without Abbott), and by José coming in to add new and exciting antibiotics into my IV tube (Cipro at 2:30 am, Flagyl at 5:30 am) and put a shot of heparin straight into my belly at 5:30. (They did that a lot over the next few days.)

     At 8:30 am, I was visited by a team of three doctors—none of them surgeons—who cheerfully informed me that my entire gallbladder was to come out. I reacted in shock. The three doctors all agreed that it was perfectly routine. I asked how many of them had undergone such a procedure. None of them had. I suggested that it couldn't be all that routine in that case. The irony was sadly lost on them.

     My shocked reaction, of course, was because I'd thought Dr. Hegazi had made it clear that the procedure I was to undergo would remove the stones and leave the bladder—but when I called him a few minutes later in an adrenalin rush, he denied having said any such thing, and asserted that "cystectomy" means and has always meant removal of the entire gallbladder. I was wondering if it was worth asking for a second opinion, but didn't know where to begin. But I talked to Donna on the phone, and she told me that she'd had no doubt, from the time I'd first told her what Dr. Hegazi had told me, that I was to lose my gallbladder. She'd thought I understood that, or she would have disabused me of my misunderstanding. So I began trying to accept the inevitable.

     [It turns out the procedure for removing just the stones involves pulverizing them with ultrasound, but it only works in patients whose gallstones are few and minuscule—which was not at all the case with me.]

     It was clear now that I wouldn't have my surgery until Monday morning. I didn't do a hell of a lot over the weekend, other than consume clear fluids (apple juice, low-salt bouillon, tea and (sugar-free) gelatin); watch a little TV (not worth it); receive a few visitors (Ethan, Deb Wunder, a chaplain whom it turned out I knew, having attended a Passover Seder in his home once, and Jonathan and Debbie Baker); try to log on to the Internet (the hospital's VPN was less than cooperative, though I finally did get a few hours' worth of connectivity Sunday, Monday, and Tuesday); and, oh, yes, ask assorted hospital personnel when I was going to get to talk to an actual surgeon and get some answers to the growing list of questions (about the duration of the procedure, the nature of the recovery process, and its short- and long-term aftereffects) I was maintaining in my Palm Pilot. They kept promising to page a surgeon, and maybe they did, but I didn't see one all day Saturday.

     However, one Dr. Autin, currently assigned to the weekend emergency surgery detail, came by around 1 am Sunday morning, between operations, to check on a patient he'd worked on earlier, and graciously consented to answer my litany of questions. He may have been surprised at my waking up as suddenly as I did and grabbing for my Palm Pilot when he walked in, but I got some answers. I even got to transcribe most of them before going back to sleep.

     Sunday I finally learned the full term for what they were going to do to me: laparascopic cholecystectomy, often shortened by medical personnel to "lap chole," which sounds like something one pays a lady in a strip club for. [Not that there's anything wrong with that.] I got a few more visits from actual doctors, mostly because they wanted me to sign some release forms, and finally got to meet the elusive Dr. Gardezi, a middle-aged man with a substantial Middle Eastern accent. He seemed nice enough, though I wasn't massively happy about being asked to place my guts in the hands of a guy with a knife when I'd only had ten minutes to form a personal impression of him. José let me know that I'd been placed at the head of the surgical queue for Monday morning and was scheduled to go under at 7:30. This was good, since I'd be placed under NPO orders at midnight in any case, and an early operation would minimize the time I was deprived of fluids.

Caveman sitting on flat table-like rock. 
Cave doctor with stone scalpel:
   "As soon as the anesthesiologist gets here, we'll get started."
In the background, another caveman enters the cave carrying a large club.
(BIZARRO by Dan Piraro, 5 April 2010)      They got me up at 6 am and down to the surgery floor by about 7. I'd taken off my watch by then, so I don't know exactly when they started prepping me, but it was pretty close to on time. The anesthesiologist put a mask on my face, and the next thing I knew, I was in the recovery room. No, make that PACU, for Post-Anesthesia Care Unit. Gotta have some new acronyms lest the uninformed find out what it is you're actually doing or not doing.

     I was in PACU for a few hours, mostly horizontal but mostly conscious, not in horrible pain thanks to plenty of morphine in my system. I had four incisions: one in my belly button, covered up with some sort of gunk so I couldn't see it; one about an inch above and to the right of it, so small I almost didn't see it; one about four inches above it, looking like a stab wound committed with the smallest knife in a kitchen set; and one about four inches to the right of that, covered with conventional gauze-and-tape bandaging. There was a small blood-drainage-collection bottle connected to this wound by a plastic tube, and a catheter emerging from my genitalia. And of course there was the IV I'd had in my hand for two and a half days.

     Around noon, I think, they pulled out the catheter—putting me through probably the worst pain I was in the whole time I was there. Not too long thereafter, I was wheeled back to my room, with a urinal (a wide-mouthed two-liter plastic jug marked off to make it easier to measure its contents) to pee in for the next day or so; an Incentive Deep Breathing Exerciser, a plastic toy with a tube I inhaled from and watched a little plastic weight rise up a channel; and instructions to get help from a nurse the first time I tried standing up or walking. (Naturally, the day nurses responded to my help requests with smiles and Real Soon Now promises, and I finally stood up and walked by myself, without incident.)

     And of course, there were drugs. For pain I got morphine plus tramadol (later changed to toradol, an NSAID); for infection they continued the Cipro and the Flagyl; and to aid digestion they gave me Pepcid or one of its relatives, plus lactobacillus. They kept me under NPO orders all day and evening, asserting that my gut needed to rest, yet they gave me ice chips by the pint, ensuring a near-constant flow of water through my gut as I chewed the chips and they melted. I do not understand this.

     I zoned in and out, looked for anything interesting on TV, tried to access the Internet (unsuccessfully), did the breathing exercises (discovering that I experienced major pain only when I inhaled deeply), asked for more pain medication, and peed in the urinal (the first time was definitely the hardest. The human urethra is not really intended to have catheters inserted and then removed cavalierly, expecially only a few hours apart). Ultimately I got up and walked around (good for helping jump-start the digestive tract and everything else, they said). Eventually I tried to go to sleep; that turned out to be the worst part, because the pain was most intense when I was horizontal. I got up early and shifted to a chair, where the discomfort levels were similar to Monday afternoon's.

Surgeon with camera, to other surgeon who is using forceps to hold one end of green squiggly thing emerging from patient's body:
"Ooo -- wait!  That's perfect for the clinic's home page.  
  Just stretch it out a little further ... a little more ..."
(THE 5TH WAVE by Rich Tennant, 17 November 2002)      I took it easy most of Tuesday, sitting in the chair rather than the bed, listening to music, and returning a couple of overdue phone calls from the previous week. My body temperature swung between 98° and 101°F, but no one seemed to think this was unusual. The wound continued to drain an evil brownish fluid into the little bottle, about an ounce an hour. At one point Dr. Gardezi the surgeon came in and told me I'd presented him with "the gallbladder from hell"—full of stones and grossly inflamed. (Later he also mentioned that it had been turning gangrenous in places.) He couldn't remember ever seeing so many gallstones in one gallbladder. Well, I had to ask. Just how many stones had he found in my gallbladder? With a slight touch of pride, he said, "About 30." But no, he hadn't saved any or even taken pictures. I was disappointed.

     Dr. Gardezi told me I had the option of checking out of the hospital that day, Tuesday, or waiting another day; he said the insurance company wouldn't balk at the extra day. I said that I honestly didn't feel sufficiently healed to leave; even if they weren't worried about my temperature swings, I was, and I also wanted to see if, for example, the sharp pains when I inhaled would go away in another day or so or whether they symptomatized something else going on that would need attention in the next 24 hours. So I opted to stay another day, figuring (also) that Ethan would be available to help me pack and get me home on Wednesday. I was now on "full liquid" diet (orange as well as apple juice, Cream of Wheat for breakfast, cloudy broth (no recognizable solid particles) instead of bouillon the rest of the day, and sugar-free vanilla pudding instead of gelatin). It was progress, anyway.

     I read, drank, peed, took the occasional walk around the hospital floor, received another visit from Deb, and tried napping sitting up in bed with the head at full up. It mostly worked, so I slept that way Tuesday night. I believe a couple of the regular doctors wandered into the room at 7 or so Wednesday morning, asked me how I was, and mumbled something about deciding whether I should go home yet. I was still mostly asleep, not to mention a touch befuddled from the morphine. There was still a drainage bottle hanging from my incision, concerning which they'd have to give me instructions before discharging me. I didn't relish dealing with the non-paying passenger for a week.

     Just after lunchtime Wednesday, though, my nurse told me the word had been given. Donna was up at the Hospital for Joint Diseases getting some tests of her own, with Ethan providing chauffeur service, so I called them to let them know. They arrived around 2:30, and I was home before 4 (with a stop to drop off my Percocet prescription at the pharmacy).

     The next few days weren't all that exciting to retell (assuming any of the above was particularly exciting). I continued to be in mild but manageable pain when walking, almost none when sitting, and somewhat more when lying down (though I did manage to sleep lying down Wednesday night and thereafter). The worst was at the moment I was transitioning from lying to sitting. I took the Percocet mostly before going to bed, but found after a few days that I wasn't noticing a lot of difference, so I quit and kept it in reserve.

     Mostly I noticed I seemed to be sweating like a pig, and consequently smelling like one; this seemed to be the result of a wider than usual variability of body temperature (probably a Fahrenheit degree or two), so that if I was cold one hour and put on another shirt, I was hot the next hour and soaking the shirt. I cursed the hospital out daily for prohibiting showers; it seems to take more time and effort to wash the upper half of my body at the sink than to do top to toes in a nice hot shower. I also found I was getting tired faster than I expected. Over the next couple of days I took a couple of trips out for supplies, and each time I found myself ready to go to bed—for ten or twelve hours—by the time I got back. I was apparently the only one surprised by this. One friend opined online that so soon after surgery, I had every reason to feel wiped out just getting out of bed.

     I emptied the drainage bottle three or four times a day as it got to looking full or feeling heavy, though since the fluid I dumped out was never more than 40 cc at a time, the weight must have been illusory. The total daily volume peaked at 160 cc on Friday and then diminished to 30 cc on Monday.

     Tuesday I went back to see Dr. Gardezi, who declared that I was mending well, and pulled out my drainage tube (which didn't hurt quite as much as pulling out the catheter had). He said I could shower any time I wanted to, could go back to work whenever, and could involve myself in whatever other exertion I genuinely felt up to. I showered that night, and the next morning I showered again and returned to work.

     So now I have three little boo-boos on my belly, each small enough to be covered by a standard Band-Aid, plus a bellybutton that shows signs of having been mistreated recently (though the caked gore finally washed away after the fourth shower). There are various internal pulls and such that I feel when I walk, so I'm walking more slowly than usual, but I'm walking to the subway each day. (The biking to work is on hold for a week or two.) My appetite is still somewhat less than I expect it to be, but I have no trouble eating the food that's in front of me. I seem to have lost about ten pounds during the whole ordeal; it'll be interesting to see how fast that comes back.

     And that brings me to the long-term effects. The gallbladder (top-ten placement notwithstanding) is a "nonessential" organ. It doesn't produce anything; it only stores bile (produced by the liver) for future use. Even without a gallbladder, that Old Gland Liver just keeps secretin' along, sending the bile directly into the intestine. Bile is used in the digestion of fat, emulsifying the globules into smaller droplets that can be worked on by enzymes. Without a gallbladder, the amount of fat I can eat and digest in an hour is limited by my liver's production of bile in that time; any more and I get nausea and diarrhea. But how great an amount is that, exactly?

     The standard recommendation for persons who've lost their gallbladders is a "low-fat" diet, but just how low in fat it needs to be to avoid digestive distress is never specified. I've talked to a few people in this situation, and the mileage seems to vary all over the map. Some say they've had to cut way back on fat, and some say they've hardly changed their diets at all. It appears that the only way to determine my limit is to surpass it and suffer the consequences. Fortunately, Dr. Gardezi points out that while I can let myself in for an unpleasant afternoon or evening by doing so, I can't do myself any further damage. The next couple of months will be a time of gastronomic experimentation for me.

     Returning to where I was before this latest crisis jumped on top of everything else, I still need to see the dental surgeon again about that root-canalled tooth (which may require some minor surgery to the jawbone around it). And I'll be bringing in Daisy the minivan this week for some long-overdue body work. And I still need to schedule an annual checkup. Feels like I'm doing a lot of running and not even managing to stay in the same place.

     And we still don't have a conclusive diagnosis on Donna's shoulder yet; a visit to the surgeon's office was followed by a visit to the hospital for some high-tech imaging, and now they want her back for more imaging. We hope to work that in this week, too.

Charlie Brown, to Snoopy on top of doghouse:
    "In southwest Cameroon there are frogs that weigh ten pounds."
Snoopy, after a pause for thought:
    "That is definitely not something to be told
     just before you go to sleep."
(PEANUTS by Charles M. Schulz, circa 1982.  
Third-generation photocopy supplied by Mark Blackman) CAMEROON, MY WAYWARD SON: Ethan left Brooklyn for the Peace Corps headquarters in Philadelphia on Wednesday 2 June (my first day back to work). He contacted us by IM that night to let us know that he and about 40 other volunteers would be bussed back to New York the next day and placed on a plane headed to Yaoundé, Cameroon. We haven't heard from him since then, but we did get an e-mail from another Peace Corps person in Yaoundé that his group had arrived safely there. The e-mail indicated that the group would be moving to another town called Bafia five days later for training. (Yaoundé is the national capital, population a million and a half; Bafia is about fifty miles away and has about 70,000 inhabitants. Thank you, Wikipedia.) That's about all we know right now.

Fringe Reception: Comments on APA-NYU, Volume 8, #5 (e-APA-NYU #73)

JAMISON, TAKE E-LETTER (Mark L. Blackman):
"As my ophthalmologist has used the term legally blind (with encroaching macular degeneration); and my orthopedist said that my sciatica & stenosis made me unable to work, I asked Social Security about Disability." Condolences about the various ailments. Abby, you did this a few years ago; can you provide Mark any advice on negotiating the bureaucracy? /*/ (¢APA-NEWS) "I note that as e-SAAC you use nycadre [at] alum.rpi.edu rather than acedsl.com." As I believe I've explained before, I use the alum.rpi.edu address wherever possible, since I can shift the address it forwards to if I change my "real" provider (which, of course, hasn't happened in over a decade). /*/ (¢self) "Ed also wanted hamantashen. I reminded him that Purim had been a couple of weeks ago." Didn't you start one of your Space Rabbi stories with Baruch Rogers in a café not long before Pesach, trying to order rugelah and being served stale hamantashen instead? You've been in this situation fairly often, it appears. /*/ (¢Cinii) "I thought that Washington Square Park's renovations were finished last year." So did I. This came without any warning as far as I know. /*/ (¢me) "I've seen pedestrian UNDERpasses in London (where they're called subways)...." Many of them double as entrances to the subterranean urban railroad, which I found confusing—here I was trying to get used to the idea that it wasn't called the subway but the underground, and then they start labeling some of the entrances "Subway." Hah? And which kind of subway was Petula Clark telling me not to sleep in?

NO SEX* ANYWHERE (Ariel Cinii):
"I've gone ahead with the decision to split my previous manuscript, 'The Touching Lands Dance' into three novellas, starting with the chapters I've already written. The hard part will be writing in all the connecting pieces that were visualized or assumed but never written." I thought it was already complete. If not, good luck finishing it. Will writing the connecting pieces be any harder if it's three novellas than if it were one novel? /*/ The stroll down the High Line and through Chelsea Market was a fun if low-key way to spend a Sunday afternoon. I'll want to go back when they've finished more of the High Line than the half-mile or so that's open so far.

I'm guessing I'll be healthy enough by the end of the month to travel down to Conterpoint (this year's Floating East Coast Filk Convention, to be held outside Washington, D.C. the last weekend of June), and of course to show up at the Staten Island Ferry on the first of July. The rest of the summer is anyone's guess. Be well, everyone, and be nice to your gallbladder (if you still have one).

>Portions of the preceding are pretty sure there are easier ways to lose weight.<

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