Thursday, December 29, 2011

Random Thoughts: Encounter With the Japanese Medical System (Part 2)

(Continued from part 1)

The lounge, such as it was. Actually, it was pretty comfortable. Santa didn't mind hanging out there. 

I was told that the surgery would happen in the afternoon of the 20th, but they didn't know when for sure because it depended on what sort of other operations were done and any complications or unforeseen issues. Admission would be from 9:30 am and they'd take me for surgery when they were ready. We checked in and a woman from the nurses station took my bag on her rattling metal cart and gave us the grand tour which included the vending machine in the hallway, the communal toilet locations, the communal shower (one for the entire third floor), and the lounge from which we must take or make any phone calls so as not to disturb patients with the noise. She also weighed me and measured my height, as they must do in order to properly calculate how much general anesthesia to administer in operations that you sleep through.

The ward area that my room was in only had one other patient when I arrived, but I had no idea what her age or situation was because curtains were drawn to protect everyone's privacy. The space was actually rather nice and included a desk and chair, dresser, and a very narrow closet as well as a bedside table with a T.V. and a tiny refrigerator. As was explained to me at the pre-admission interview, you needed to insert a card into the television and pay extra if you used it. Since I'm not a fan of Japanese T.V., that was not really a concern of mine. I had my “entertainment” mapped out with an iPod full of books on tape and my antique P.D.A. (a Palm device) full of eBooks. The space was bigger than expected with a “nice” view of an adjacent roof. Okay, so the view wasn't great, but I wasn't there to have a holiday. However, I did get to see the sunrise rather beautifully through the window on the last day of my stay.

My bedside. Yes, that's debu neko there to comfort me!

In addition to being told the bleeding obvious (there's your bed, your dresser, etc.), a little paper with columns and spaces for dates was placed on the bedside table and I was told to record the type and frequency of every trip to the bathroom. I found this slightly amusing on one level, but I do recognize the medical value on a less juvenile one. Such information assists in knowing about your recovery and any potential problems, particularly when compared with the pre-op survey data in which they ask about your usual toilet habits. The staff had helpfully assisted in the completion of such information with me in English during the pre-surgery consultation. Such questionnaires are frequently the bane of a patient's life when they are seeking routine treatment and they wonder why doctors need to know how often a patient poops when they're there for something like a bad back, but I know they need to know as much as possible and had no complaints.

Things moved rapidly from there as the nurse in charge of me on that day prepped me. This included changing my clothes and having me put on dark blue paper pants, a white cotton tunic, and a short lavender yukata (a sort of short kimono-like robe made of cotton that ties shut). This surprised me because you're told to bring your own pajamas and I figured that I'd go into the operation in just a paper gown and with no underpants at all. When I was 12 and had my tonsils out, I remember the nurse telling me I had to take the panties off prior to surgery and I recall wondering why on earth they needed my posterior all naked and exposed when they were dealing with my throat. No one explained to me that they were going to put a catheter in and they cut off my pants during the tonsillectomy. I realize that the notion of a catheter may be too complex for a kid, but all they had to do was say that I might pee myself during the operation so they would need to use a tube to catch it and then I would have understood and complied with their request instead of rejecting it as illogical.

At any rate, the paper pants weren't actually paper, but a fabric woven from light fibers. It turned out that the yukata and gown were actually very temporary attire as when I got to the operating room, they took it all off of me except the silly paper pants. After the preparation nurse got me undressed from my street clothes and re-dressed in hospital fashions, she struggled for a long time to get in an I.V. and connected me up to a bag of saline with “100 kcal” written on it. Mmm, breakfast! Of course, I know you can't actually eat because there is a high risk of regurgitating and asphyxiating during surgery if food is in your stomach. They also need to feed you glucose before the operation to deal with catabolism, but it does seem a bit like “all of the calories and none of the fun” when you're fed through a tube.

Because I'm neither vain nor stupid, I passed most of the check she did without difficulty. That is, I was not to be wearing jewelry or make-up and wasn't silly enough to have put on either. The thing that no one mentioned to me and that I certainly did not anticipate was that my fingernails would need to be cut off. Though they are hardly exceptionally long, they are also not short. Usually, I keep them at a medium length, or more truthfully, varying lengths depending on which ones have broken off in different points in time. I'm still not sure why I needed to clip them all off, but I complied without complaint. I'm sure there was a good reason someone wasn't telling me (like putting a pulse monitor on my fingers?), just as was the case with removing my undies when I had my tonsils out. My husband remarked that there would have to be at least one or two women who undergo one of those extremely popular long and glittery nail jobs who would be angry at having to send them all into the trash bin because of surgery. The final thing was that the nurse struggled to get my hair tied back and put it into two very long and ridiculous pigtails. It might be cute if I weren't 47, but it just made me look like I'd let a 6-year old play with my hair.

Four days, right here, and that's my husband's foot. The bottom drawer of the bedside table is the refrigerator.

At this point, we were playing the waiting game. I had to just lie in bed tethered to the I.V. and talk to my husband, hoping that the earliest possible time for my surgery would be the one. It turned out that it was and at 1:15 p.m. I was walked down from my third floor room to the second floor operating area. Even this I found a bit strange as I recall being wheeled down in my previous two surgical experiences. I didn't mind except that my glasses had to stay behind and I was slightly blind and wheeling my I.V. stand over some metal floor parts (like the elevator entrance). They let my husband go with me to an outer area and from there I was laid out on the table in a position which is now a little too familiar to me. My husband told me later that they told him he couldn't wait in the outer room of the 2nd floor, which was odd since there were seats there and it looked like where people were supposed to wait, but they gave him a cell phone and said they'd call him when things were over. He went up to the lounge, which wasn't as stiflingly hot as my room, and waited.

In the operating room, they struggled with the I.V. bag to get me out of the tunic and yukata. They then asked me to put my hair in a net, which was probably better than them trying to do it as I have super long and voluminous hair. I was covered with a sheet and strapped down with Velcro so I resembled someone secured on a cross-shaped bed. This brought back a strong memory from my tonsil removal experience when my arms were taped down and my nose got itchy while I waited. I desperately wanted to scratch it but couldn't move. I remember fighting to get a free arm then the lights going out on me as the anesthesia kicked in. Fortunately, my nose behaved this time. A nurse brought over some things with Velcro attachments and strapped them to my calves. She told me that they were leg massagers and before I could fully process the strangeness of this, mentioned that they were to prevent embolisms (thrombosis).

I have failed to mention this before, and I'm sure, again, that this is standard medical procedure worldwide, but I was asked my name again and again by various people at various points in the pre-surgery preparation and in the lead-up to the surgery. I'm certain I was asked, “what is your name,” no less than six times before going under the knife. The final time was when the doctor himself came in and asked me my name and what I was being operated on for. It seems silly, but it was actually reassuring that they were so cautious about not doing the wrong surgery on the wrong patient.

About 10 minutes passed between my arrival and the doctor showing up and during that time, one of the assisting surgeons (possibly the anesthesiologist), asked me my name and told me when the doctor would arrive and that I'd be asleep and unaware while it was all happening. I know you're supposed to be in dead blackness while under anesthesia, but I recall clearly that I dreamed during my gall bladder surgery. In fact, I remember that I dreamed about my in-laws, oddly enough. This time, I dreamed again, though I don't remember what it was about. Unfortunately, dreaming contributes to confusion when coming out from under the anesthesia. They always say, “don't move”, but I am so disoriented by the move from the dream world to the new painful reality that I struggle in my bonds anyway.

As I lay there waiting for the doctor and trying not to be cold (they asked me if I needed a blanket, but I refused because I'm stupid like that), I tried to take careful note of everything happening around me. Lullaby music was playing to various tunes. The nurses counted to 5 (“ichi, ni, san, shi, go”) twice. I was later told by one of my students who is an operating room nurse that this is how they count the sponges (gauze) before the operation. They do it to make sure they don't leave one in a patient. Various staff went about their business largely out of my field of view from the table and the doctor showed up earlier than expected. They put a funny-smelling and ill-fitting oxygen mask on me and I wondered if my big, foreigner nose in a Japanese-size mask was the problem or if that's just the way they all fit sometimes. After the requisite identity check, the doctor told me that in Japan they show you what they remove at the end of the operation, but if I didn't want to see it that I didn't have to. I told him that I had heard they show you what they cut out, and that sometimes they even save some removed parts. He said they can't save them, though when I mentioned parents save the umbilical cord from their child's birth, he said, “Oh yeah, they save the umbilical cord.” He also said he felt Japanese folks were just curious about such things and I told him I'd have a look at what they removed, having no idea what to expect.

Pictures of Jesus doing miraculous things were dotted all over the hospital. It was surreal since it's not something I have seen much of in Japan.

The doctor said before starting, “Because this is a Christian hospital, we will pray before the operation,” and he said a brief prayer (in English) asking God to make the operation go well for me. Somehow using my name in the prayer specifically felt comforting because it made me feel very humanized by the doctor when I've often felt dehumanized, like a bit of meat that needs fixing, when being dealt with by some medical professionals. Of course, this is all in my head. I'm sure he recites this as a standard prayer and almost certainly is not a Christian (as few Japanese are), but I don't see any value in minimizing or dismissing feelings. I just remember them.

I'm not a Christian anymore as I couldn't reconcile the dogma with the way the world works and rejected it when I was 15 and sitting in a history class pondering such things in the mental vacuum of “self-study” time. However, the prayer made me feel a little better. If one can effectively appeal to a greater force to improve the outcome, I see no harm in making such a request and I appreciate the sentiment and positive energy regardless of the focus or words used to make it. This is why I am grateful when people pray for me and my health and safety, even if my beliefs differ from theirs. After all, they may have it right. Who am I to express greater certainty in this matter?

After the prayer, they told me they were going to give me the anesthesia and I watched them inject it into the I.V. and waited for the the lights to go out. After about 30 seconds, I was gone. When I came out of my dream, I could see the doctor standing to the left of the bed and he said the operation went well and he held up a small Ziploc bag and said that was my tumor. I was still pretty drugged up, but I said what I thought, “It looks small.” He said that it was actually pretty big, but to me it looked like a tiny bit of meat in a baggy. I guess it's all relative. He also said that, from a visual perspective, it didn't look to be cancer because it had no telltale signs and didn't encroach into surrounding tissues. Of course, they still have to test it to be sure.

A sheet was used to lift me off the bed and convey me to my room on a gurney and I was given the full Borg treatment. There was so much incredibly uncomfortable equipment attached to me that I really did feel like I had become one with the machines. I was fed through the I.V. and told there'd be no din-dins at all for me until tomorrow. I peed through the catheter. Oxygen was being pumped into my nose through tubes because apparently I couldn't be trusted to breath efficiently on my own. There was a drainage tube inserted into my chest and a little plastic bottle collecting blood pinned to my restored yukata. What was more, I was tethered to a device on the bed that continued to run the leg massagers which were attached via a cord design that would make H.R. Giger proud. On top of all of this, I had monitors attached to me that linked to a machine on my I.V. stand. This type of monitor was the bane of my existence during my stay. It kept ringing an alarm at random intervals believing in its tiny electronic brain that I had expired. During the night, when my ward-mate and I were trying to relieve our post-surgical misery with unconsciousness, it's incessant braying was maddening, though not nearly as aggravating as the fact that the nurses were in no hurry to come by and fix the screeching monstrosity.

The operation took about 2 hours and most of the rest of the day was spent lying in my bed and being grateful for the pain medication shot I was given. The odd thing, at least to me, was that after having my neck cut across about 6 inches (15 cm.) and a bit of a gland sliced out, they only gave me it after I specifically requested it. You know those movies and T.V. shows where the patient is sitting up in bed post-surgery looking all fixed up and in the pink? That's not the way it works in cases in which your condition is not very bad pre-surgery. I was fine when I entered and miserable when it was over. Now, I was wounded, exhausted, and suffering both the indignity of being hooked up to a bunch of contraptions meant to make sure I remained alive and I was in true pain. You're often in a much worse state after surgery, not better, unless it's an emergency. Even when I had gall bladder surgery, it was easier dealing with occasional pain than dealing with post-surgical distress. Of course, in the long run, I'm better off, but in the short run, I seriously wonder why I would subject myself to such torment to stave off potential future trouble. Of course, the answer is “the big C”. If cancer is lurking in that enlargement, it is better to take it out now rather than wait for it to develop.

Post-operation, I spent most of the remainder of the day lying there alternately nodding off and struggling to communicate with my husband despite the pain in my throat. This was after throwing up 9 times due to the effects of the anesthesia. I knew this was coming since it happened after my gall bladder surgery. Of course, there's no food or water in my stomach, so it's all yellow bile. That sounds gross, but it doesn't smell like and isn't as voluminous as normal vomit. So, while certainly unpleasant, it's not quite as disgusting as an after-drinking-binge hurlfest. My ever-supportive and patient husband sat by the bed touching my leg or holding my hand for hours until he had to leave at 8:00 p.m. when visitors were given the boot. Three hours after the operation, they wanted me to walk so they gathered up me and all of my various devices. After unhooking me from my “Alien-style” leg massagers, I trotted around the small third floor pushing the stand with my glucose bag at the top and a bag of pee dangling at the bottom of my attention-seeking monitor on a pole.

Upon standing up, I realized that they had taped my bandages to just under my chin such that I couldn't actually fully lift my head. Standing upright, I looked like I had a bizarre neck injury. There's nothing like roaming the halls in a semi-drugged and greatly pained state in a flimsy gown and ill-fitting short yukata in full visibility of patients, visitors and hospital staff with your excretions in full view. However, I trooped through without complaint, because there are certain things I know about getting out of the hospital and one of them is that they are more likely to let you go on-time, or early, if you show you can move.

The other thing I know about escaping from the hospital is that they watch how much pain medication you consume. The more you use, the more skeptical they become about your recovery. With this in mind, I didn't ask for another shot that first night. I was in pain, but it wasn't unbearable. I've had worse, which is to say I've had back pain so excruciating that it was unbearable and I wanted to die. This wasn't nearly that bad. Imagine ten times the pain of a paper cut for the incision (they do hurt a lot, you know) and three times the pain of the worst sore throat you ever had and that was where I was. So, if I could endure so much worse before with my back, I could put up with the aching in my neck and throat. Or at least that is what I told myself as I lay there suffering and being awakened by the monitor's alarm every few hours and thinking that all wanted to do was get out on time or early.

One of several enduring frustrations during the day after surgery was that I was tethered so completely to the bed, but I was clearly capable of walking. I could stand and walk with little difficulty (except pain from the stress of movement on my cut muscles), but they wouldn't unhook me and let me go to the bathroom by myself. If you've never been subjected to the indignity of a catheter, you're not going to understand why this was a big deal, but they're extremely uncomfortable and mine made me feel like I constantly needed to urinate, even though I was already doing so automatically. It made it extremely hard to rest and added another layer of discomfort.

The most lasting impression of being in the hospital that I had this time was that it was damn near impossible to get good rest there. If my machines weren't blaring, someone else's were in rooms down the hall, and loudly enough to wake the whole floor. The nurses were just as reluctant to attend to their screeching mechanisms as they were to mine so we'd be awakened at regular intervals throughout the night by their malfunctions. Sleep repeatedly interrupted was topped off with the nurses waking us up between 6:30 and 7:00 am because that's when we were supposed to get up. The nurses were unfailingly kind, helpful and cheery, but they were also loud. They thought nothing of having extremely noisy conversations in the ward or in the hall throughout the day. There was no way of making up for lost nighttime sleep with daytime napping with that racket.

In fact, like most professionals in Japan, the nurses were clearly trained in a method that they adhered to without question and without applying selective reasoning. One of those routines was that each morning the day and night nurses introduced themselves and said goodbye. This is all nice and friendly on the surface. However, I learned the drawbacks of it on the first day after surgery and being sleep-deprived due to the cacophony. I had breakfast and blissfully fell back asleep. Rather than thinking that it might be a good idea to leave sleeping patients in pain lie, the night nurse and day nurse cheerily yelled, “ohayo gozaimasu” (good morning) to me and woke me up from my short-lived peaceful slumber. I got about 20 minutes of post-breakfast napping then was aware of my full-body discomfort again and back to fatigued misery.

Regarding the food, that was the only aspect of the hospital stay that I was regarding with curiosity and anticipation. Since my gall bladder surgery was all performed and completed in one day, I had only eaten enough to prove I was ready to escape at that time and I wanted to see what Japanese hospital food was like. This hospital has a policy of serving “lacto-ovo vegetarian cuisine” (their words in their English pamphlet). That means dairy and eggs, but I'm guessing no fish and, of course, no meat. Unfortunately, 36 hours of nothing but bags of saline with glucose (100 calories per bag!) was followed by a liquid diet because of fears that my swallowing would be compromised by inflammation. Still, it was better than nothing, but not by much. I'm going to detail the food in a companion piece on my snack food blog, but speak of it a bit here.

First breakfast after the operation. The hobbits would also have been disappointed and hoping for a second one. 

Breakfast was a weird sweet kudzu soup called kuzuyu, decaf coffee that was little more than brown water (but, hey, I could put sugar in it... but no milk), vegetable broth that would need a lot more salt to come close to having some flavor and a tiny container of melon gelatin. It wasn't exactly the feast after my famine that I'd been hoping for, but I ate it all up nonetheless. The bigger problem was that I was shackled to my devices such that I couldn't even walk around to the other side of my bed, let alone go to the communal sink in the ward to get water, and the nurses seemed to be perplexed by my repeated requests to have my water cup filled. One thing I can say for sure is that pitchers of water are kept at hospital bedsides in the U.S. unless fluids are restricted and this hospital didn't follow that habit. Every time I asked for water, which was only when they came by to check me as I didn't want to bother them (though they did come by to poke or squeeze me pretty often), it seemed to take 20 minutes to return with a tepid 2/3 full medium-sized cup. I don't understand why it was so difficult to do when there was a sink not 15 feet away.

As I lay there tired and spending most of my time staring at the ceiling feeling exhausted and listening to William Shatner reading absurd Star Trek novels, I got increasingly frustrated with being dehydrated and having my urine siphoned off by a tube that hurt. They kept saying they wouldn't take it out and frowning at the output in the bag. I got the impression that they didn't want to remove it because they felt I wasn't peeing enough and they were concerned about kidney function. I wasn't going enough because they wouldn't give me any but the smallest amount of water! In the end, they finally agreed to unhook me from the catheter, but insisted that I “show” them when I went to the bathroom. They put a plastic container in there to catch it and I had to run for a nurse when I went. I did as ordered, she came in and frowned at the volume and said “not enough” and asked me to call her next time. If I'd known it was going to be a test, I would have tried harder.

In the end, and this reminded both my husband and I of a Monty Python sketch at an insurance agent's office, they gave me a freaking enormous jar (I'd guess about 6 liters) and told me they'd put it in the bathroom and I'd have to decant all of my urine into it for the next 8-10 hours. Frankly speaking, though I thought this was peculiar, I'd rather be emptying my pee into jars than have it siphoned off by a torture device. And though I wasn't exactly having a good time, I did understand their need to measure output. I just didn't like how they didn't give me much water and were not making a connection between these two issues.

My husband came to visit me as visiting hours began at 3:00 p.m., but that was quickly spoiled by my ward-mate hobbling over and saying he was too loud and could we quiet down a bit (though I wasn't actually speaking and spent most of the time typing sentences on the iPad due to my throat issues). At the time, I felt put out because, though his voice does carry and he can be loud, it was not exactly very early or late and he was entitled to visit me. Later, I felt bad about being irked because I gained a lot more sympathy for her need to rest. It turned out that she had come in for some gynecological issue and the surgery had complications so she was on the table for 6 hours. From the moment I arrived on Tuesday at 9:30 am to the time I left at 10:00 am on Friday, she was still wincing and whimpering in pain every time she moved. Given how noisy it was all night there, I'm guessing she also did not get enough rest and was far worse off than me in every way.

I learned later from her that she spoke English quite well, albeit with a German accent as she worked in Germany and Singapore. I assumed she didn't understand what we were saying, but perhaps part of the source of her frustration upon overhearing our conversations was that it was much more to her than verbal white noise. It was an actual distraction she comprehended. She also kept turning off the lights and I believe she was in so much pain that the over-stimulation of sounds and lights were just more than she could endure. Of course, the nurses kept turning the lights back on again for their own purposes. Personally, I didn't care about the lights being off because I could listen to books on tape in the dark.

By 8:00 p.m. the day after surgery, I had finally been fully de-Borgified except for the little drainage tube and bottle of blood pinned to my P.J.s and could fill my own cup of water, though I was still filling the giant pee jar well into the night. It was a lot easier to fill it up with having control of my own liquid intake. I'd also had two more lackluster liquid diet meals and was starving. I had brought a bag of snacks along with me and consumed two strawberry cookie-type bars. I know this made me a “bad” patient, but I knew the restrictions on my diet were not based on nutrition or blood sugar, but rather on my swallowing ability, and I knew I could handle it. It was no harder to eat those than to suck down the gluey little bowl of “rice water” that they fed me for both lunch and dinner.  

(To be concluded in part 3).