"from there to here"

origins

It's really hard to say when this process started. I first saw my family doctor about a surgical remedy for my obesity in the spring of 2000. She referred me to my (still current) psychotherapist. As a result of the reflection I began to do in psychotherapy I decided to defer the procedure. I decided I was doing it for the wrong reasons and I wasn't really prepared. That was a conclusion I came to on my own, but everyone supported it.

The next milestone with regard to deciding to have surgery was in late 2007 when my psychotherapist suggested to me that I re-visit the question of surgery. I did not respond positively to that notion, I quoted her a bunch of lab results as evidence that I was not at the point medically that justified surgical intervention. She backed off (to her credit, I believe).

In May 2008 I went to see a cardiologist on the advice of my family doctor, she wanted to get some baseline studies done just based on the fact that I am an obese man of a certain age. I went along with that mostly because I was quietly concerned that there might be something to worry about. I had all the risk factors: centrally-carried obesity, male gender, history of hypertension and diabetes. It would almost be surprising to learn that I didn't have some coronary artery disease.

I had an echocardiogram, it was normal. My cardiologist recommended bariatric surgery to me like it was a blood pressure pill, casually, I mean, and as if it was a fait accompli. I was a bit put-off by this, but I had the presence of mind to ask him how much weight-loss he'd have to see to rescind that recommendation, he told me so many pounds in this much time. Going forward, I didn't hit that mark.

So, in March 2009 I went to see a surgeon. I did it then because a dear friend confronted me with my inaction. It was a disastrous appointment, I was seen almost three hours late, and then only for 10 minutes, and the surgeon recommended a gastric bypass procedure, which is major surgery that I find prima facie objectionable. I was as disinterested in having my anatomy rearranged as he was disinterested in my opinion. But, he did clue me on to the fact that they had discovered endrocrinologic mechanisms that gave bypass an advantage as a treatment for type-II Diabetes. I heretofore did not know that. This was a turning point for me, though I didn't know that at the time.

I redoubled, re-tripled my efforts to lose some weight and as usual, I had some success and then hit a hard plateau. About the same time my diabetes worsened and I became an insulin-dependent diabetic. The double-whammy of having a successful period of weight loss met with a worsening of my Diabetes was new and shocking.

I began taking a modern chemically-engineered analog of insulin that pharmacodynamically allows for a once-daily dosage (called insulin-glargine, branded Lantus). My blood sugars rapidly returned to near-normal, but now I was injecting myself with a needle daily.

Don't be misled by the seemingly obvious reasons for my extreme distaste for becoming an insulin-dependent diabetic. The injections are not painful. Doing them is not that much trouble (I can go from taking out the medicine before an injection to putting it away after the injection in less than a minute). I'm a nurse. I'm good at this.

My distaste has to do with my self-image, and it is related to my distaste for surgery. I have a lingering self-hatred that is directed mainly at people who I identify as being obese because they take really lousy care of themselves. Further, this variety of the obese dress like they never look in a mirror, as if they can't find clothes in their own size, and they seem almost willfully defiant of standards for physical appearance. I really find these people distasteful.

I used to be one of those people. That description fit me in my late 20's and most of my 30's. I was healthier physically, but I was angry about the social (mostly romantic) rejection I suffered. So, to distract myself from that pain, I defiantly rejected standards of what is an acceptable appearance. I wore clothes that were ill-fitting, ill-maintained, and I did only the amount of medical self-care necessary to stay free from acute pain. I let both my hypertension and diabetes go untreated. Even my dental health suffered.

That's no longer who I am, but I still, on some level, regard choosing bariatric surgery and having my type-II diabetes worsen to insulin-dependent status as the inevitable last toll-free stop on the road to hell for a willful, self-hating, defiant, self-neglecting person afflicted with obesity. Notice, this sadistic self-critique is not the childish bullying of skinny peers. This is self-inflicted. This notion has interfered with my progress in seeking a remedy for my problems for much of my life.

Now, perhaps fortunately, the urgency of my declining medical status compels me forward. I returned to the bariatric surgery practice and requested that I be evaluated for a less-extreme procedure, the adjustable laparoscopically-placed gastric band, known colloquially as the lap-band, or "what Al Roker had done." This required that I change surgeons, as I did, and I began the work-up for that procedure, more comfortable with placing a device than cutting up my GI tract and re-routing it.

gastric bypass drawing

The gastric bypass makes a small pouch out of the stomach and hooks that pouch up to the small intestine, about 2/3rds of the way along. The rest of the stomach and bypassed intestine remain intact and are also re-attached downstream, so to speak, draining bile into the distal segment of the small intestine. This has the effect of restricting the physical amount of food one can take and also decreasing the amount of nutrients absorbed from it (fats aren't broken down until they mix with bile, for example). You eat less and absorb less.

The lap-band simply restricts the amount of food one can eat. The rest of the GI tract is intact, you absorb food just as you did before. That was what I wanted, I even fantasized about taking it out someday and "being normal" again.

Well, we had a date and I was tumbling toward that procedure, with everyone encouraging me to do the bypass instead. I refused. I am a nurse, I know who is ultimately in charge, and I let everyone know that it was the lap-band or nothing at all. They all relented. I was to get a lap-band placed on Wednesday, December 9th.

Then, they found out they made a mistake on my insurance coverage (a so-called negative wallet biopsy) and neither of the surgeons in the practice would get paid for operating on me. That brought everything to a screeching halt and I was really down, lower than I have been for a while. Despondent.

Here I was, having finally cleared the emotional hurdles I needed to clear to get to signing a consent form, and I couldn't get it done because a billing clerk made a mistake. I have worked alongside medical billing operations most of my life, I know how mistakes are made, I know how easy they are to make, so I didn't really get as angry as I become frustrated and annoyed that health care finance is like this.

A couple of days after that I got a call from another surgeon. He is just out of training and has applied to be a provider under my insurance plan. He wants to talk to me. He tells me he's willing to place a lap-band if that what I choose, but he'd like to talk to me before we decide on a procedure date. He asks me to google something in the meantime. That was a good sign.

next - Choosing the sleeve gastrectomy