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Thyroidectomy and a Side of Diabetes

Eric Lagergren

January 14, 2010

For those of you who follow my blog, you may recall that last Thursday, January 7, was the date for my thyroidectomy. I would like, then, in this week’s entry to share with you an update I sent to friends and family last Saturday about what life was like for me in those hours before and after surgery.

Here I am on a Saturday evening composing an e-mail of what’s happened over the past two days. I must warn you first, however, that:

(1) I really have nothing else to do tonight, so this will probably be a long e-mail. Those of you who aren’t interested in details don’t have to continue reading (I provide a lot of details).

(2) About an hour ago I took a Vicodin, and as I discovered last night when I e-mailed my surgeon to let him know how I was doing — also after taking a Vicodin — I tend to have some lapses in narrative coherence when typing with that stuff in my system.

(3) Because of the drug referenced in #2 above, I have no qualms linking to a picture of my neck if you want to see it at 36 hours after surgery. Please note that there is no “gross” or “eww” factor in the picture. You’ll basically see my neck with piece of tape known as a Steri-Strip on it. Oh, and they shaved off most of my chest hair for the operation.

There was really nothing exciting about preoperation on Thursday. My wife and I arrived when we were told to arrive (11:30) and ended up sitting in the family surgical waiting room for an hour. Finally I was called back to pre-op, where I got into the hospital gown and they hooked me up to the monitors. For a couple of hours I lay in one of the stalls while various members of the surgical team and nursing staff came by and asked routine presurgery questions. By this point most of my anxiety about surgery had disappeared. For those of you who don’t know, I’d had some worry about going under anesthesia a few days before the surgery. That calmed, however, after talking to a friend who’s a certified registered nurse anesthetist, because I knew at that point that once I was under, that was it: I’d wake up and my thyroid would be gone.

Had I known the misery I’d experience in the hours and the night and morning following surgery, however, I probably wouldn’t have had such a relaxing pre-op experience.

When it was time for surgery, I’d already had some of the happy relaxing juice injected into my IV, so most of what happened at this point becomes somewhat fuzzy. They say that sometimes people remember being wheeled into the operating room and sometimes they don’t. I remember it, and I remember them putting the pressure cuffs on my calf muscles. What I thought about as the three or four people around me were working on prepping me for the operation was how comfortable and contained — packed in, really — I was on the operating table. I managed to mumble something to the residents, anesthesiologist, surgeon, and whoever else was in the room, something about how I was reminded me of the squeeze machine Temple Grandin designed for herself. I babbled on for probably five or ten more seconds about this, most likely trying to show them I had some lucidity. “You know,” I said to the doctors, “she’s that woman who designed more humane abattoirs and she was the subject of that Oliver Sacks essay in his book An Anthropologist on Mars?”

The last thing I remember before falling into sleep was someone saying, “If he’s quoting Oliver Sacks, we need to give him more anesthetic.”

The operation was supposed to last anywhere from two and a half to three hours. At least that’s what we’d been told. Well, we’d heard different things from different people. Duration of operation in reality: over four hours. This, of course, didn’t matter to me, but it was not good for Kathryn, who after the third hour had become a nervous wreck. She’s since told me that that time between hour three and when they finally told her I was in post-op was the worst hour of her life.

After the operation, she still wasn’t able to see me for at least another hour and a half. It was now around 8 or 9 in the evening, and Kathryn hadn’t seen me, hadn’t been home to take care of the dog for the evening, and would have to — when she would eventually leave for home (around 11) — endure a twice-as-long drive because the Ann Arbor area got about five or six inches of snow that day.

At this point I would say that I had a much easier time of it. Being the patient is the best thing to be during an operation.

During.

That hour or so after waking in post-op is still (and will always be) kind of fuzzy. I don’t remember when Kathryn came to be by my side, and I don’t recall how time seemed to pass. I’m not sure of much that happened. The nurse, at my request, maxed me out on morphine. I was in a lot of pain, and when she kept asking me if I was in pain, I’d say yes. If she asked if I wanted more morphine, what was I going to say? No? So it simply came to pass that very soon I was maxed out on morphine.

I was also irritable. I wasn’t really cooperative. Not really communicative, either, although that wasn’t by choice. I was unable to tell anyone anything because I couldn’t talk, and this was a problem that would complicate things for me for the next ten hours or so. I tried to drink some Diet Coke in post-op, but I couldn’t keep it down. What I mean is, I couldn’t even swallow. I’d choke, cough, wheeze, get my breath back, and try again ten minutes later. Same thing.

I was also hot. And cold. One minute I’d be drenched in sweat and kicking my blankets off, the next minute I’d be freezing. The post-op nurse who sat with me said to me, in that kind but insistent nurse way, “Honey, keep your blankets on you because you have to remain decent. Don’t show the rest of the world everything.”

The nurse told Kathryn and me that they’d had difficulty intubating me because I have a small airway. They temporarily damaged my vocal cords trying to insert the endotracheal tube, and I’m still having difficulty breathing two days later (although it’s getting much, much better). Also, during intubation, they chipped my left front tooth. I’m assuming this happened with the laryngoscope. Superficial, though. No root or nerve damage. But this meant that on Friday morning, even though I felt like complete crap, I would be wheeled down to the dental department in the hospital so they could smooth down the chip. Whether or not I’ll have the tooth reconstructed remains to be seen.

Once they moved me to Surgical Observation, where I’d spend the night (I was expecting to go home the next morning around 10 or 11), I tried again to drink liquids. Every time I took a small sip, though, it felt to me as if some of the liquid was going into my trachea. I’d cough, and choke, and wheeze, and feel as if I was drowning. But I kept trying. I was so thirsty.

That night in observation I slept maybe two hours total. For the majority of the night I was in such discomfort that I sat up cross-legged in bed and just focused on breathing. I have asthma, and I know what an asthma attack feels like. That’s what this felt like, but there was no relief from it.

I wore my insulin pump on for the surgery (no one was allowed to mess with it, those were the orders from my endocrinologist), and while my blood glucose ran high for most of the night, that’s better than going hypoglycemic. Once I’d started fasting for surgery, I had been instructed by my endocrinologist to dial back my basal rate by 0.1 units per hour. The morning before surgery my blood glucose numbers hovered around 150. In the hour before surgery I was at 130. I could spend a lot of time talking about my assumptions regarding surgery and diabetes. In short, I figured that even though I had my insulin pump that they’d keep my Type 1 diabetes first and foremost in their thoughts.

But it doesn’t always happen that way. For most of the time I was in post-op and then in Surgical Observation, my blood glucose was in the mid-200s. I couldn’t figure out why, and I didn’t have the wherewithal to enter into an extended conversation about why these high numbers might be occurring. I simply figured it was because of the stress my body had undergone. Then, at 3 or 4 in the morning, a nurse came on shift and checked my glucose and told me what the high numbers were (around 284 at this point). I issued a correction bolus, and then a few minutes later she came back and replaced my IV bag. She said that she was changing to a bag with just a solution of saline. What? (I really couldn’t say that, but it’s what I was thinking.)

That’s right. My high numbers were due to them giving me an IV with dextrose. I assumed they’d know what to do for someone with diabetes (I mean, yes, they do know what to do); and I guess I assumed that if they gave someone with an insulin pump an IV that could alter his sugars that they’d tell me so I could correct for it. But they didn’t. Once we fixed this, by 8 or 9 on Friday morning I was back in the mid-100s again.

All of this time, however, I still couldn’t talk beyond a whisper. I couldn’t swallow without severe pain or liquid entering my lungs. And I couldn’t cough voluntarily. And oh how I wanted to cough. After surgery, after anesthesia, a body needs to cough. Phelgm, etc. Yet because of the intubation problems, coupled with the movement of nerves that become temporarily damaged during the thyroidectomy, I couldn’t cough or swallow or talk. (They have to move the nerves off of the thyroid in order to remove it, which stretches the nerves.)

Being unable to swallow scared the hell out of me. I’d heard that I’d probably be hoarse for a week or so after surgery and that I’d have a sore neck, but I was in much worse shape than I thought I’d be.

The doctors said they wanted to do a swallow study to determine the extent of the damage to my throat. I had no idea what a swallow study was, but around noon a speech pathologist came to my room with jello, pudding, applesauce, a fruit cup, and some fruit juice and soda. I have to say that my care overall while in the hospital was great — despite the intubation difficulties — but the speech pathologist was the best. His demeanor put both Kathryn and me at ease. He was thorough in his explanation of what can happen during a thyroidectomy to the voice box, the larynx, the nerves, the epiglottis, the blood vessels, as well as going over with us in detail the stages of swallowing and what potentially was going wrong with my swallowing mechanism.

He did some tests to see what types of liquids and foods I could and couldn’t swallow, observing the mechanics of how I did so and explaining why I was doing what I was doing. The speech pathologist determined — after he retaught me how to swallow until my nerves recovered — that I would be able to eat a normal diet. The kicker, though, is that for the next week or so whenever I drink any liquids such as water, Diet Coke, or coffee, I have to take a small sip, then breathe in through my nose, hold that breath, then tuck my chin down to my chest and swallow. Every time. This prevents the liquid from moving into my windpipe. For more viscous materials, such as pudding or applesauce, or solid foods, I will take a small bite, chew, hold it in my mouth, and then move my chin to my chest as far as I can and swallow (although I don’t have to hold my breath when I swallow foods).

If I swallow normally, without moving my chin, it feels again as if I’m choking (and believe me, I’ve made that mistake several times today).

That’s pretty much it. I didn’t have a restful first night back home. I just couldn’t get comfortable. And not being able to voluntarily cough when I needed to (and oh how I’d need to) is one of the worst things I’ve experienced. But as of tonight, as I sit here in our guest bed (my recovery room for the next week), I’m feeling about 80% better. I still can’t move around much without getting winded, but that’s to be expected after the trauma my body underwent two days ago.

As for what’s next, and “did they get it all”? Well, they took out the entire thyroid. There were a few other nodules (lumps) on the thyroid, and by the middle of next week we’ll know the pathology reports on those, the extent of the cancer, as well what the results are on the lymph nodes they removed around the thyroid. That information will determine the amount of radioactive iodine therapy that I’ll have to undergo in, oh, probably two months or so. That’s another fun time to come, time in the hospital, and then time sequestered from friends and family since I’ll be radioactive.

Take care, all.
Eric

Update: On Tuesday afternoon (January 12) I received a call from my surgeon to see how I was doing and to give me the results on the pathology for the thyroid and the lymph nodes. There was indeed papillary thyroid cancer on the nodule they went in to remove, but that was the only location they found on the thyroid (they found two other nodules, but both of those were benign). They also removed 11 lymph nodes around my thyroid, and all of those were negative for cancer. This is all good news. They got all of the cancer and it hadn’t started to spread anywhere.



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