A surgeon, A midwife and a GP

Recent health scare

Over the weekend I became really unwell with symptoms that I have been suffering from for a number of years but this was worse and lasted from Friday evening until the end of Tuesday. I have been looking back through my blog posts because there are a number of themes that led to be becoming so unwell. I also need to express my anger and disappointment at the fact that the last two years of suffering could have been avoided if a certain professional person had done his job properly.

Background

Roux-En-Y Gastric Bypass Surgery for weight loss

I began this blog Friday, October 24, 2008 two weeks post op of my gastric bypass surgery for weight loss.
My first experience of the excruciating pain that was going to dog me for the next two and a half years was at four days post op.
Four days post op I had an epidural removed and was thrust 2 panadol in exchange for the complete block and tramadol injections I had been having for the initial post op recovery. My body seemed to go into complete melt down approximately one hour after the epidural removal. I had severe epigastric pain which eventually spread all over my trunk leaving me leaning over the bed moaning, rocking and groaning as I tried to escape it. Despite a full load of Fentanyl given intravenously the pain was not relieved and I just had to ride it out.
As you can read in this post the following day of starting the blog, I was still feeling uncomfortable enough to need to take regular paracetamol. I blog about trying to teach my then 7 year old how to knit but having to abandon it because I am too sore.
The clear problems with communication with the post op nurse are described in this post. I am amazed now at how useful it is looking back through my blog and reading the difficulties I was having communicating with this nurse. I describe being cut off, how she didn't appear to be listening and despite the 30min allocated appointment length it was over and done with in 10-15mins! Please bear in mind I'd pain $25,000 for this surgery out of my hard earned midwifery caseloading money.
I didn't record my next major post op visit where I actually got to meet the consultant himself again. Pre op I had tried once to enter into a two way conversation and I was abruptly stopped. He held his hand up to my face and said, "my dear I do not say these things so you respond, I say these things so that you listen. You are not expected to talk back to me." Ominous sign you may think? Well at the time there were 10,000 gastric bypass surgeries going on in New Zealand and this particular consultant took care of at least half of them. I wanted someone who would definitely know what he was doing when he opened me up. So yes, I did put technical ability above bedside manner but perhaps to my cost. This pre op consultation style set me up for my post op consultation with him. A month following the initial surgery I had had a repeat session of the severe pain I had suffered day 4 post op. I was unable to get out of bed, moaning, groaning and my daughter had an anxious time calling her dad at the surgery to come home and see to mum. Chris my GP husband accompanied me to the post op visit with the consultant and he was amazed at my unusual lack of forthrightness and submissiveness in the visit. Near the end he felt he had to step in and say, "are you going to tell him about the pain?"
My pain was instantly dismissed as 'oesphageal spasm'. It was my fault, I was told I had obviously tried to undo his work by eating too fast and not taking proper care. The pain was there to remind me of this fact and I was reminded that he had saved me from diabetes, arthritis and had improved my life expectancy. So this set the tone for me really and for the next two and a half years every time I have had the pain I have thought, "Pamela it is your punishment, you have done something wrong, you have eaten incorrectly it is oesphageal spasm."
This tone was set really as whenever I visited the GP for follow up I played down the pain episodes, got around mentioning them and started to try and hide as many episodes from the family as possible. This has meant that for the last two and a half years I have been taking paracetamol regularly as many as 6-8 a day, everyday. Recently it got to the stage where I've been unable to leave the four hours between dosages and have taken 1.5mgs as an attempt at a 'loading dose' that anaesthetists sometimes prescribe instead of the recommended 1mg dose. I also found recently that if I took paracetamol with a glass of wine it had a better effect. Dangerous thinking alcohol doubles the effect of paracetamol on the liver.

Bloods


I was supposed to have half yearly blood tests to measure my full blood count, glucose, liver function and vitamin B12 levels. Without being too complicated I became fearful of the liver function tests. Liver function is measured mostly by (and I am not going to spell out the big words I am just going to use the initials), AST, ALT, GGT, Bilirubin, albumin and ALP. For a link to a really easy to read and understand guide to interpreting these tests click on the words above.

TABLE 1  Helpful Hints for Interpreting Liver Function Tests Situation Comments Mildly elevated ALT level (less than 1.5 times normal) ALT value could be normal for gender, ethnicity or body mass index. Consider muscle injury or myopathy. Alcoholic hepatitis Laboratory values can appear cholestatic, and symptoms can mimic cholecystitis. Minimal elevations of AST and ALT often occur. AST level greater than 500 U per L The AST elevation is unlikely to result from alcohol intake alone. In a heavy drinker, consider acetaminophen toxicity. Common bile duct stone Condition can simulate acute hepatitis. AST and ALT become elevated immediately, but elevation of AP and GGT is delayed. Isolated elevation of GGT level This situation may be induced by alcohol and aromatic medications, usually with no actual liver disease. Isolated elevation of AP level (asymptomatic patient with normal GGT level) Consider bone growth or injury, or primary biliary cirrhosis. AP level rises in late pregnancy. Isolated elevation of unconjugated bilirubin level Consider Gilbert syndrome or hemolysis. Low albumin level Low albumin is most often caused by acute or chronic inflammation, urinary loss, severe malnutrition or liver disease; it is sometimes caused by gastrointestinal loss (e.g., colitis or some uncommon small bowel disease). Normal values are lower in pregnancy. Blood ammonia level Blood ammonia values are not necessarily elevated in patients with hepatic encephalopathy. Determination of blood ammonia levels is most useful in patients with altered mental status of new onset or unknown origin. ALT=alanine aminotransferase; AST=aspartate aminotransferase; AP=alkaline phosphatase; GGT=gamma-glutamyltransferase. At one point before coming to Australia my blood tests had been done and because I wasn't telling anyone about the pain I had received a lecture about how I was probably drinking too much alcohol and I pretty much felt like I'd been labelled some sort of alcoholic. This had a knock on effect I began to avoid all my check ups all together and I was refusing to have my blood tests. I felt like an opinion had been formed and everyone was going to believe I was a raging alcoholic. This last weekend  This last weekend everything accumulated and erupted. Friday evening the old familiar feeling of the beginnings of the pain started. An indigestion spreading from the epigastric area , across my chest, under my ribs and a stabbing pain in the middle of my back. The epigastric pain crescendos into acute spasmodic rhythms not unlike labour contractions but felt in the chest. I started with my usual methods of pain relief. The warm bath, I had found it really useful in the past but in New Zealand we had a huge spa bath, very deep which supported my abdominal pain and allowed some relief. In Australia we have a very old shallow bath nowhere near deep enough. I tried my next option the hot water bottle. Usually I need it so hot that the skin blisters, great for distraction therapy but no good for long term pain relief (the skin doesn't respond well). I then gradually become more and more internalised much like I did when in labour, moaning, groaning, stopping my feet and rocking to try and relieve the pain. Unfortunately unlike previous episodes which have lasted 40mins to a maximum 8hours I was still suffering on Sunday afternoon at which point pain induced vomiting began. Chris finally put his foot down. I was still refusing hospital, A and E, sorry I have a general mistrust now of surgeons and nurses, and I didn't want to get to the hospital, have the pain stop and then feel like a complete dick for wasting every one's time. I just kept thinking, another 10 mins, it might stop in another 10 mins. Chris came home and said I have made an appointment for you at the Drs for tomorrow  (Monday morning) at 09.45. And so, my week began. I saw the GP. I had to drive to the surgery with a bucket in the car so I could pull over and vomit. I had to lie down in the surgery. I was basically at my wits end, the pain had stopped but I was fearful of its return my reserves were spent. I was basically tired and tearful as well. 1st up were the blood tests following some IM stemetil I frailly took myself over to the lab. I was very scared at this point because I knew I had been taking too much paracetamol to try and cope with the pain. I thought my liver was beginning to fail. The blood tests came back, Chris came home and said scarily, "Congratulations you have some of the worst liver function test results I've ever seen". The grim look on his face said it all and I knew he was thinking of a worse case scenario. This just sent me into denial. He asked, "How do you feel about that?" I just busied myself in the kitchen trying to make dinner for the girls and said I didn't have time to think about it. That night I did though when the pain returned and I thought everyone was sleeping. I was cold and I thought it was that that had woken me but then I felt the familiar spasmodic rhythms again. This time though I had received dire warnings from Chris. I must stay away from the paracetamol and so I decided I would search the internet. I searched out the worse case scenario's liver cancer and cirrhosis and decided I might only have five years to live. Fitfully I finally managed to get the odd few minutes of sleep. So the next 48hours were pretty scary and I had a full range of emotions but mainly tried to keep them hidden from everyone. Tuesday I had a liver and gall bladder scan. The best case scenario outcome was gall stones. This is where I return to the origins of my anger. The consent for my original surgery included gall bladder removal because it is very very common to get gall stones following gastric bypass surgery. However he did not remove it. He never explained why but my surgery was running 2-3hrs late that day and I believe it influenced his decision. He wanted to be away on time, often in the private sector surgeons are charged extra if the run over their allotted theatre time because theatre staff need to be paid on call money or overtime. Unlike in the UK where we could charge the patient as we went along for services (I was a scrub nurse in a BUPA hospital prior to midwifery), I was on an upfront fixed fee in New Zealand. This means any extra costs incurred come out of the surgeons own pocket. Summary  I believe if he had done the thorough job in the first place, I wouldn't have suffered. If the nurse and the surgeon had been effective communicators, which means effectively listening as well as talking, I might not have suffered. If I hadn't been made to feel judged or assumptions made about alcohol causing my raised blood results, I wouldn't have started to hide my symptoms. If everyone just cared a little more and did their jobs a little more effectively, I wouldn't have suffered this much.