Well Rounded

Or, having a full hip replacement pre pre-menopause.

The day before I left the hospital, my blood hemoglobin (the stuff that carries oxygen to cells) was less than half what it should have been (60 g/L, 6 g/dL) and I had to have a blood transfusion. When I left the hospital, it was only up to 80 g/L.

Four weeks later, I was still occasionally feeling dizzy if I stood up quickly. That's a sign of low hemoglobin. I asked my physical therapist and my family doctor about it. Blood hemoglobin levels generally return to normal by 3 weeks post-surgery. What was the problem? Was it due to internal bleeding? "Blood in your stool?" they asked. Nope. Had I been taking iron supplements? Yes.

Then, my period started, right on schedule. My body has been busy lining my uterus with bloody padding (blood that I needed to have circulating!!) since a week post-surgery, because right after traumatic, major surgery? It's obviously such a great time to get pregnant. Yeah. Thanks, body.

I’m not an expert on healthcare policy, but since I’ve been talking about my experiences with the healthcare systems in the US and Canada in recent posts, I would like to lay out a few facts.
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Michelle and I were having a discussion last week about the meaning of health. To me, good health has always been mostly perceptive: physical competence, a high energy level, a feeling of buoyancy. Adequate health is defined by an ability to do the things I need to in order to get through the day. Poor health would be marked by an inability to function.

Of course, it helps to have the perception of good health confirmed by good medical numbers; by being in as many low risk groups as possible. But, what if the numbers aren’t good? What if you have a chronic condition or a permanent disability? Is it still possible to be healthy? Well, I’ve fallen into the “obese” category since I was a kid, and I consider myself fundamentally healthy. I would imagine that it’s also possible to have that high energy, buoyant feeling with well-managed diabetes, or in a wheelchair.

Maybe health means homeostasis; being stable and balanced and functioning well within the parameters you’ve set for yourself. If that’s true, then is it healthier to be at a higher, rather than a lower level of physical function or are there just a lot of different ways to be healthy? Interesting question.

Another question: if you define health as the absence of disease, what happens when you start to redefine disease? What happens when you, for example, say that:

BMI = weight/height squared
Obese = BMI > 30
And obese = diseased?

Where is the pathogen? There isn’t one. Where is the suffering? The only inevitable suffering is caused by other people’s attitudes. Where is the life-threatening event? Again, none. So, how can obesity be considered a disease, let alone an epidemic? It’s just a risk factor; positive for some real diseases, and negative for others.

I feel healthy because my body is climbing its way back up to a higher level of functioning, and doing it quickly. So, maybe health is either feeling balanced, or moving to a higher level. Maybe unhealthiness is moving downward toward a lower level of functioning. One way to look at it…

What do you think? What IS health?

In my first post on the hip replacement topic I said that I was feeling healthy, and here’s why: I’m healing fast. Everyone is saying “Don’t push yourself!” and “You should give yourself time to heal.” Honestly, I feel calm and patient, but every day I can do more, so why not do it? Fourteen days post-op – yesterday - I took the public transport for the first time. I met someone for coffee. I’m morphing from a patient back into a human being! I was brave enough to ask people to give up their seats on the bus and the train when I had to, and climbing up and down the stairs with the cane was no big deal.

While yesterday was super-active, today I’ve been a complete lazy ass. I took a 3-hour afternoon nap and I haven’t even done my physical therapy exercises. Also, my appetite has returned. Don’t get me wrong. I’ve been feeding myself well all through the recovery. I knew I needed the energy and nutrients. But, honestly, I could have taken the food or left it. I just wasn’t interested in eating. Today, however, I was actually hungry. I ate a small breakfast. I ate a medium-sized lunch. Then in the afternoon it was dried fruit and chocolate almonds, and then it was vegetable juice and potato chips. Twice. Then a light dinner.

I’ve been really wanting food; really enjoying food. And, um, my husband is looking pretty damn tasty, too. Those have got to be signs that I’m getting back to normal.

While the hospital had an extra-wide walker for me, the Red Cross (who I’m renting home care equipment from) didn’t. So, I’ve been walking exclusively with a cane since I returned home on day 5. Lately I’m using it less and less around the house, since I can walk without it a little bit. My staples are out, and I can take a shower again. No more sponge baths! The physical therapist says I’m out on the leading edge of where I should be, recovery-wise. I’m back to doing most of my jobs around the house, and I feel strong, healthy and energetic. I think that my body is going to come through this with blazing colors. I’m going back to work on Monday, at least part time.

Just a couple of weirdnesses:

1. Periodically, I realize that I have a foreign object in my body and I panic. I’m not the type of person who would ever, say, get breast implants. I’ve always refused to diet because I think that my size is natural and correct for me. Every time I dye my hair, I feel like I’m betraying myself a little bit. Deep down, I have a weird, hippy-like purity fetish. I want to be natural, and I want to be wholly myself. On some level, the idea that my left hip has been sawed off and replaced with a manufactured joint is deeply disturbing to me.

2. I love having the dressing on the wound changed. See, I’m fiercely independent and have never really allowed myself to be taken care of by others. But, the process of having the dressing over the foot-long incision in my left hip changed daily by my mom (the first week) and my husband (the second week) feels really beautiful. These are the two people I’m closest to in the world. It’s strangely intimate and it makes me feel loved, accepted and cared for. The wound is so damn ugly and scary-looking, but they carefully uncover it so that it doesn’t hurt too much, and then they clean it, and then they wrap it up in layers of gauze, compressive tape, more gauze and more tape. And they say reassuring things like “it’s healing really well.” Pretty soon it won’t need to be dressed anymore, and I actually think I’m going to miss this ritual.

Anyway, I don’t feel at all like myself yet, physically, but I believe that I will soon. I'm very close to being able to meet the minimum demands of normal life. Yay!

Previously, I talked about my experience with the US health care system back in 1989. They fixed the things that were making it impossible for me to function normally. However, the surgeries weren’t well explained, there was no follow-up, and there was no attempt to figure out what the car accident had done to me. When I asked about testing and monitoring, I was told there would be none - to wait and see. And, I also posted on some larger issues I have with being a patient.

Here I am in Canada, twenty years later. I moved to Toronto for graduate school, met my husband, and decided to stay. I’ve been here for five years and am a Canadian permanent resident; a landed immigrant.

Two years ago, my left hip, broken and dislocated 20 years ago, finally gave up the ghost. I struggled with it for a couple of years and then decided to get the hip replacement surgery.

Here’s how it went down:
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Surgery is violent and surgery violates your body. They cut you open and change things inside you.

I’m very close to my body. You could even say that we’re inseparable. I respect my body. It’s aggressively healthy; it swings hard toward homeostasis. It’s incredibly resilient. It’s coordinated and balanced, big and bottom-heavy, shaped like the goddesses’ bodies in some Renaissance paintings. I’m vain, and I’m protective of my body. I don’t want some random cowboy in a lab coat fucking around with it. Especially (and I have to say this) because many doctors probably think that I am deeply flawed – even worthless or a burden on society - because my size. Deep down, I don’t trust doctors to act in my best interests. I suspect that some of them want to punish me.

I really did go for those 20 years with only a few visits to the doctor, and that’s one reason for it. The other is this: Much of the time, when you take your car to a mechanic, they fix something and break something else. Human bodies are vastly more complex than cars, and doctors don’t understand them as well as we may think. With surgery especially, but really with any kind of treatment, there are often unforeseen consequences. They try to fix the thing that your body can’t beat on its own (in this case, continuous deterioration due to osteoarthritis), and in doing so they create problems that hopefully, your body can beat. This clearly requires a risk/benefit analysis. Medical interference is never without risks and is rarely without repercussions.

Anyway, the direct results of the surgery – for example, the long wound with staples up my left hip, the huge bruise up my left leg, the swollen knee and ankle, the internal damage around the joint – are horrible in and of themselves. They look and feel, physically and emotionally, like evidence of abuse, like the aftermath of being hunted, or like the result of a violent, catastrophic accident. They represent a frightening loss of control and they engage the deepest survival instincts – to hide, to seek the help of those you trust the most, to avoid further danger.

But, surgeons are not (generally) abusers or predators. They do what they do to help; to improve the function of bodies. They tear you up with the hope that they are healing you. It must be a difficult job for surgeons who are emotionally engaged. But, I suspect that to some extent, they need to see patients as meat, which is what surgery makes you feel like.

Surgeons are butchers and patients are meat. Deep down, we know that. Surgery leaves me physically restless and emotionally raw. And walking into it willingly… it’s very difficult for me. Non-emergency surgery requires you to choose this loss of control, to put your life into the hands of doctors. Doctors who, as a group, disrespect or even hate fat people. And, in the end, it takes away the face you show to the world: an educated voice, a direct manner, bright eyes, a quick laugh, good posture, flattering and professional-looking clothes, a lack of awe and an ability to connect with impressive people. Suddenly, I’ve lost all that. All of the class signals that I employ to contradict the message my body size and coloring send are stripped away. I lose my privilege and I lose my voice. I’m just a fat brown woman on a slab; an object that I don’t trust doctors with. It’s frightening and it’s dehumanizing. Under these circumstances, medical treatment, especially surgery, feels like a violation. I suspect that it feels that way to everyone with a strong sense of physical autonomy.

There are things that can be done to minimize the fear, the feeling of violation, and the perceived loss of control. The abdominal surgery that I had in the US was almost a worst case scenario. Even after the surgery, I was treated like a non-person. Things weren’t explained to me, and quality of care was poor. The hip replacement that I just had in Canada was much better.

I’ve had surgery twice before, and both times were 20 years ago, right after the car accident. The first surgery was to snap my hip back into its socket. The second was to remove the scar tissue that was blocking my intestines and causing me (after a night of horrible cramps) to barf up every normal-sized meal I tried to eat.

The first operation was emergency surgery, and the second was planned. I was 19 years old and lived in Michigan at the time.

I don’t remember much from the first surgery, when my hip was snapped back together; just a kind, Indian orthopedic surgeon who said “I’m only a carpenter” when I thanked him. The shattered pelvis couldn’t be set into a cast. It was just left to mend on its own. So, I went off, healed at home and taught myself to walk before the physical therapy was supposed to start; walked into the appointment where they were planning to teach me to use crutches, and never went back. We had poor insurance; automotive coverage and a cheap HMO. There was no oversight on my care, and nobody explained anything to my mom and me; how physical therapy was not generally considered optional, how the hip was almost certainly going to fail in the future.

Mom did her best to manage things. At the time, she was a single parent with me at University and my brother in middle school, working full time and going to law school at night. Somehow she (5’ tall and 120 pounds) and my brother (11 years old) dragged me (5’-5” and 190 pounds) up to the second floor of our little house, where the only bathroom was. I think that I actually sat on pillows and we went up one step at a time, backwards, with me pulling myself up on the railing to help. And once I was up there, I was stuck, so you can imagine that regaining my mobility was a high priority. Nobody in my family could lift me.

A month later I was back in my apartment in Ann Arbor, working at a summer job. But I had a problem. I was in a lot of pain, and I couldn’t keep food down. So, I went in for one of those tests where you drink a radioactive shake. We found out that my intestines were full of scar tissue and were almost completely blocked in places.

The second surgery, honestly, was kind of horrible. Abdominal surgery, I’ve heard, is always bad. I was in the hospital for two weeks (I think), and I remember all kinds of intense discomfort. The catheter, the IV, the tubes up my nose. I developed an infection around those tubes, and it was excruciating. I remember telling a nurse “take these out right now, or I will.” The catheter was awful, too. I hated the morphine drip. The staples in my belly pulled and gapped, and the scar was horrific at first. When I left the hospital, I promised myself I’d never have unnecessary surgery; I’d do everything possible to avoid ever having another operation. But it worked. Afterwards, the pain stopped and I was able to eat normally again.

The two insurance companies sent the bills back and forth for years. They tried to deny that the second operation was related to the car accident. Mom had collection agencies after her for almost a decade. And, again, there was no oversight of my case and no follow-up. I was left wondering what other damage may have been overlooked. Would I be able to have kids? What kind of shape were(/are) my lungs in? They’d been crushed in the accident and afterwards lost a lot of their capacity – and I started getting bronchitis every winter. No testing was ever done. No doctor was ever willing to try to figure out the extent of the internal damage. So, I put up with the bronchitis every year and took care of myself as best I could.

Those were my experiences with the health care system in the US.

I Feel Really Healthy

And that might seem like a weird thing to say under the circumstances, which are these:

I'm at home after surgery. I've had a full left hip replacement. They cut me open, cut out part of my pelvis and the top of my femur, and pinned in a ceramic joint. The surgeon kept the replacement piece as short as possible so that it can be done at least twice, maybe three times in the future. The ceramic joints last 15-20 years, and I'm only 40. Then, they stapled shut the 10" long incision on the back of my left hip.

Incidentally, I donated the bone in the ball and socket that were removed. Did you know that they make paste out of donated bone and mix it with adhesive to use in filling holes and resurfacing bone, just as you might with sawdust and glue in a wood floor? Interesting fact.

Why was this hip replacement needed?

Well, I've told the story of the car accident and finding out about the resulting trauma-induced osteoarthritis on this blog before. It's been downhill - fast - since the condition was diagnosed a couple of years ago. I'd been forced to give up dancing, squash, hiking, and long walks through the city. The chronic pain in my hip was variable, but getting worse. After a while, even aquafit and swimming aggravated it. I had started to take ibuprofen to get me through the day. When I look at recent photos of myself, it's apparent that my left shoulder is lower than my right shoulder; that my left hip had worn down.

Two weeks ago, before the surgery, I was still taking the streetcar to work and walking a kilometer to and from home. On a good day, I could still run a short distance. I didn't limp (until I'd been walking for at least a few blocks) and I didn't carry a cane. People at work were sort of puzzled about the hip replacement thing, because they couldn't see anything wrong with me. But, the sports medicine physician I'd been working with had told me the first time he saw the X-rays that I was going to need a hip replacement, and that the timing would be up to me. I had wanted to make my hip last longer than this, but it just wasn't going to fly.

I had good reasons for choosing to get the surgery done now.

The bad hip has been limiting my career options. I'm a construction industry engineer, and I had been doing work that involved building assessment. That meant sometimes being on my feet all day. I'd recently switched to a desk job, partly because I didn't think I could handle building inspections for much longer (but mostly because it's a really cool job!) The desk job is a contract position, and it ends in October. I'm enjoying the work and am hoping I'll be able hang onto the position after the end of the contract, but having options is always a good thing.

I have pretty high expectations for my level of mobility. I like to go on backpacking trips. When I’m traveling, I explore the place I’m visiting on foot. I love to dance. I was taking NIA classes before my hip got bad, but I’d also like to try belly dancing; anything, really, that involves moving to music. I have a handsome 32 year old husband and would like my sex life back, please. I work less than 2km from where I live and would like to walk to work and back instead of taking pubic transport. I enjoy racket sports and would like to be able to play squash with my husband again, so that he stops accusing me of cowardice and re-learns how to lose gracefully.

It's not a luxury to want your body functioning well. I live Canada, I pay into the public health care system, and I deserve care. Everyone deserves care. And, it's more efficient to replace a bad joint before it deteriorates too much. According to a Globe and Mail article on a recent Canadian study - published the week of my surgery - "'We need to find the sweet spot – the time when we should be intervening that most benefits the patient and is most cost-effective,' ... The new study suggests that this is at a time when a patient has significant pain from arthritis but has not yet deteriorated to the point where they are disabled by the lack of function in their joints." That would be where I was, exactly. Perfect timing.

Finally, my husband and I are considering having a kid. Maybe. Actually, we're going to stop trying not to have one. In any case, I don't want to risk being pregnant with a bad hip.

But, I still felt a little guilty about it. Isn’t that crazy?

There are plenty of people, fat and thin, who are less active than I was two weeks ago, before the surgery.

A lot of fat people - particularly people who are very heavy - live with a lower level of mobility than I had before the hip replacement and would attribute it (perhaps correctly - although mobility is never about just one variable) to their weight. It occurred to me that I was planning major surgery to solve a mobility problem. I'm vehemently anti-WLS, and I know that many people get weight loss surgery for similar reasons. The difference? Well, WLS damages healthy digestive systems. Joint replacement surgery replaces a faulty joint. But still.

I often see people who appear to be in worse shape than me limping around the city. Why am I getting fixed and they aren't? At times, I've felt as though wanting the level of mobility I'm used to for myself is ablist.

Choosing to get the surgery this early seemed like a privilege. The damage was limited to my left hip and hadn't seriously impacted my right hip or my back. The things I couldn't do are things that many people never bother doing, anyway. Maybe, as a middle-aged fat woman, I didn't deserve to have such high expectations. I mean, if I really wanted to be fit, I'd be willing to starve myself - right? Weighing 220 pounds would be unacceptable to me - right? That thought was floating around at the back of my mind like a toxic cloud. And, that's the attitude that I half-expected from the doctors. After all, in some places, they won't give people my size joint replacements. Some people probably think that I don't deserve a hip replacement. They'd take my weight as evidence that I'm non-compliant; that I don't care about my health. And, I am non-compliant. When doctors tell me to try to lose weight, I tell them "no." I tell them that I'm perfectly willing to stay active and that I eat a balanced diet, but that I won't count calories, and I won't exercise to burn calories. I will not drive myself crazy that way, and I won’t get onto the diet rollercoaster.

Thankfully, the doctors who have worked with me on the hip issue, a sports medicine physician and a respected orthopedic surgeon (e-mail if you live in the GTA and want to know who they are), are better than that. They listened to me, and they planned my treatment accordingly. I told the sports medicine specialist how active I was up until a couple of years ago, and he believed me. He took my desire to stay active, the fact that it was important to me, seriously, in spite of the fact that I'm an unrepentant fat lady. I told the orthopedic surgeon about the car accident; about how I recovered very, very quickly from the shattered pelvis and dislocated hip and about how I'm basically in the same shape I was in at 19 and would probably recover quickly again. I let him know that I hoped to be back at work 2-4 weeks after the hip replacement. He believed me, and he planned my treatment accordingly. I've never felt so respected by doctors before. It's been such an incredible relief. Neither of them ever weighed me, but, with a BMI of 36, it's hard for me to believe that they wouldn't have noticed that I'm fat.

I'm 10 days post-op now, and I'll post more about the surgery and recovery in the next few days. I want to say some things about this as it happens, because trauma always fades out of memory.

We humans are just a bunch of monkeys with big brains. So much of what we do is about establishing a pecking order; a social hierarchy.

What's the worst thing about being fat? I'd argue that it's the social repercussions; the way it can drag down social status.

I've been using this fake dichotomy for years to defuse and reverse power dynamics in my family and my social circles. It doesn't really have anything to do with body size. It doesn't require you to exemplify what you describe, either. You can also speak in the abstract, refer to the experiences of people you know, or say you're "working on" things. It's all about roles and expectations.

Here's how it works: Someone - normally someone older and/or thinner than you are - notices that you are fat, realizes that it puts you in an inferior position, and (to be charitable) assumes you'd like to change that by changing your body size. Of course, this will require them to help you out.

They, sansei; you, grasshopper.

Keep in mind that this is not an inherently evil or nasty thing to do, that motivations will vary, and that said motivations are probably at least partly subconscious. Also, keep in mind that you probably know more about this stuff than they do. Nothing beats a friendly power flip.

You can change
Their role: wise, well informed, experienced, disciplined, helpful advisor
Your role: ignorant, on the wrong path, in need of their wisdom

into
Their role: ignorant, on the wrong path, in need of your wisdom
Your role: wise, well informed, experienced, disciplined, helpful advisor

with just a few choice words.

It boils down to this: first, you ask about their motivations. Then, you disassociate the motivations from weight. Then, you explain how they can meet (or, you've met, or, someone you know has met) those goals without dieting. If you're feeling especially frisky, you can complete the flip and start lecturing them on building self esteem, becoming more fit without restricting food, improving your health independent of weight changes, and/or looking better without being thinner.

them: I'm on this great new diet/eating plan!!
you: Really? Why do you want to lose weight?
them: I just feel awful when I'm this heavy. I get out of breath going up a flight of stairs. I can't keep up with other people.
you: You know, if you started exercising regularly, you would be in better shape and feel more at home in your body. It sounds like your problems are more about fitness than weight.
them: But, it feels awful to exercise when I'm this heavy.
you: I know a lot of people your size and larger who work out. Why not start out at a level that feels comfortable, and work from there? Maybe your weight will adjust and maybe not, but you'll feel better and be able to do more...

them: I'm on this great new diet/eating plan!!
you: A diet, really? Why do you want to lose weight?
them: I really hated the way I looked before, and clothes looked terrible on me.
you: I used to have that problem, too, but then I got a better haircut and found some great new sources of plus-sized clothes. Now I really like how I look. What kind of problems do you have with the way clothes fit?
...

them: I'm on this great new diet/eating plan!!
you: A diet, really? Why do you want to lose weight?
...now it's your turn.

What do they say, and how do you flip it around?

Today, it's going to be actual, un-reworked pencil sketches. Here's the story on these.

I was a chubby little girl. In fact, except right after growth spurts, you could probably say I was fat. I grew up in the 1970's, in the Detroit area. I was a tomboy and a risk taker. I rode my bike all the time. I jumped it off big piles of dirt on construction sites, rode it on steep hills around a pond in the woods, and could stand on the seat and even the handlebars after I'd gotten going fast.

I'd become aware that I was "fat" at about the age of 6, and I think that's why I never took gymnastics or dance lessons myself - but my friends did, and they taught me things. I could do handstands, flips, cartwheels, and roundoffs. I also loved to rollerskate and was good at it.

I don't know what I looked like doing all those things, because my dad kept all the family pictures after my parents split up, and we've seen very few of them since. All I have are copies of my school pictures:

Me at 7: Me at 11:

Anyway, there's a lot of panic about "childhood obesity" and how awful it is right now. I just want to say that I was a fat kid, and being a fat kid doesn't mean being a couch potato, being depressed or socially isolated, being physically incompetent, or having health problems - not in my experience, anyway. I've made some sketches of myself as a kid, doing some of the things I remember doing. I feel proud of myself as a kid; that I was brave and adventurous and that I didn't listen to people who told me that I had an ugly or unhealthy body - I just kept on pushing it to see what it could do.