Anaesthetime

Going Under

So I was wheeled into the little anteroom by the operating theatre; the connecting doors were open so I could see into the main theatre room, which was a bit weird. The first thing they do (reassuringly) is to check you're the right person, both by asking you and by checking the ID tags on your wrist and ankle. Then it becomes a bit of a flurry of activity really; you have to untie the hospital gown so it's basically just an extra blanket, make sure your glasses are labelled before they take them off, etc etc. The various anaesthetists and nurses and assistants are really lovely; both times I've had a general anaesthetic, they've done a stellar job of distracting me and keeping me feeling pretty calm about the whole thing.

I had a mask with some oxygen flowing to breathe while they put a cannula in my left wrist. The anaesthetist warned that I might feel a little sting as the anaesthetic was administered, but it was actually surprisingly painful as it moved up my arm. Upon waking up I discovered that at some point the vein had blown, they'd taken that cannula out and put one in my right wrist instead, so I don't know if that would explain why it hurt more than I expected. Equally possible I guess is that it always hurts like that but most people forget once they've been knocked out?

Incidentally, common misconception about cannulae; they're little flexible plastic tubes that sit inside the vein, they don't have needles in - the needle is just used to insert it and is then removed.

Waking Up

I woke up gradually and was fully awake by about half-past twelve; there was a clock opposite my bed. Immediately I took this to be a good sign, as I knew I'd had the general anaesthetic about nine. Given that it would have taken some time to get me into and out of the theatre, that vaguely indicated an operating time of around three hours, which implied there probably hadn't been much in the way of complications like, say, a cerebrospinal fluid leak. Lack of complications is good.

The first thing I noticed, of course, was pain: I didn't have much of it. The second thing I noticed was: there were no bandages in my nose! Last time I had transsphenoidal surgery, my nose was packed with rolls of wadding afterwards, and having it taken out was a pretty unpleasant experience. This time? Nothing. My nose was a little delicate, but it was bandage free and, remarkably, not even oozing at that point. A lovely nurse explained they had filled the wound with a kind of foam, which sets hard and then dissolves slowly. Occassionally over the next few days I would feel it creaking slightly in my head and sinuses, which was an extremely weird sensation but happily caused no actual pain.

As expected, I was really thirsty and my throat was sore from the tube they put down it. The very nice nurse came and asked me my name and where I was, and brought me a cup of water. With a straw. On reflection, maybe I should have remembered that you're not supposed to drink through straws after pituitary surgery, and in hindsight the three cups of water I proceded to drink using said straw may have contributed to the epic nosebleed I experienced some time later once I got back onto the ward. But it's hard to think straight when you've only just woken up...

Ear, Nose, and Throat

When I got my appointment to see the ENT people, I learned a new word. Not panjandrum (although that is another new word I learned recently and haven't had the chance to trot out yet) or fissiparous (likewise), but otolaryngology. Which, it turns out, is the proper name for Ear, Nose & Throat. I had always vaguely wondered why other medical departments got to use such fancy names - cardiac for heart, renal for kidney etc - while the poor Ear, Nose and Throat people were stuck with a name that sounds like an extended edition of the popular children's song "Heads,Shoulders, Knees and Toes". Turns out they do have a fancy name after all. Who knew?

So I went to see the otolaryngologist. I went into his office and he asked about the problems I've had with my nose and sinuses since my first operation - I still use a nose spray twice a day because otherwise it's too painful. He was very nice, right up to the point where he announced he was going to put a camera stick up my nose.*

Firstly I had to have a topical anaesthetic, which was administered as a nose spray. It went right down my nose and numbed the back of my tongue as well, which not only felt incredibly strange but tasted revolting. Then after giving it a few minutes for the anaesthetic to work, out came the camera stick which was slowly fed into my left nostril. It wasn't too bad at first, although it was incredibly freaky to see quite a long stick disappearing into my head. I felt like one of those "human blockhead" circus sideshow acts where they hammer nails into their nose, except it was uncomfortable enough even with topical anaesthetic that I can't imagine volunteering to do it without one.

Then once the camera was at the back of my nose, the otolaryngologist started poking around more, and that was genuinely painful; it was quite hard to keep my head still and my eyes were watering. Then of course, he had to do the other nostril.

The good news was that there's nothing much wrong with my nose, although part of one of the structures inside (I cannot for the life of me remember what he called it, and Google has been no help) has ended up knocked sideways, probably from the surgery. I just have to keep using the nose spray I already take, indefinitely. It may eventually clear up, or it may not.

Then after the pituitary surgery, I'll go in to have a check up with ENT once I've healed up. After the operation I have to use a nasal wash, which sounds pretty gross - basically it involves putting saline solution up one nostril from a little pot and rinsing it around inside your nose. Eurgh. I have heard of this before, I believe it's quite common in India and Pakistan and that part of the world - I believe in Pakistan recently there was an outbreak of cases of naegleria fowleri, a particularly nasty brain-eating amoeba (no, I'm not making this up) as a result of people using water that hadn't been boiled to wash out their noses.

So the moral of the story is: boil the damn water.

Ahem.

Anyway, then I returned home to regale my housemates and boyfriend with the story in glorious technicolour detail, by which time thankfully the anaesthetic had mostly worn off and my face was starting to feel a lot more normal again.

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* N.B. In fairness, "camera stick" is not the term he used.

Round 2 With Neurosurgery

So, back to the story of my various experiences way back in November! A mere two months late...

On the 5th November, I had an appointment at the Neurosurgery clinic - as I discovered less than a week beforehand. I had been very nervous about it, but I turned up at the hospital on time, and went through the strange procedure in Neurosurgery where they seat you in one waiting room for five minutes, then lead you through to a second waiting room further along the corridor shortly afterwards. The last time I had apre-surgery appointment with Neuro, I was kept waiting for about three hours, so I had come prepared with su-dokus and a lengthy novel - but amazingly this time I was only there for around twenty minutes.

 My second surprise when I was shown in to see the surgeon was that he was actually the surgeon named on my paperwork; previously when I went to meet the surgeon, I just met a member of the surgical team, not the leading surgeon dude himself. But there he was, complete with a trainee doctor who was shadowing him for the week. It's a teaching hospital, so I'm quite used to having an assortment of medical students sitting in on my appointments; the highlight was probably a charming exchange student from Japan who was assigned to the endocrinology department. When an endocrinological emergency meant that we were sat alone together in my endocrinologist's office for twenty minutes, he admitted that he had no desire to become an endocrinologist himself, but we did have a very nice chat about Japanese medical schools.

So, I sat down and the neurosurgeon mentioned the results of my recentMRI pituitary scan, and seemed surprised to hear that no-one had told me about them. Back when I first became a patient, when I had an MRI someone was guaranteed to phone me and let me know the results, but alas in recent times this seems to have completely fallen by the wayside, and it's so much hassle trying to call up and find out myself that I tend to just wait until my next appointment to find out.

It was good news; the pituitary tumour hadn't grown since the previous scan in July, and in fact if anything they thought it might have reduced in size slightly, although it's difficult to tell with these things unless it's a substantial change. I had the scan at the end of October, by which time I'd been on my lanreotide injections for two months continuously, and before that I had an injection in August which lasted for a month, followed by a month without medication before the injections started again. So it looks like they were effective at controlling the pituitary tumour growth, which is excellent news! Although I've had the injections before, they've never really looked at whether they had an effect on the size of the tumour by scanning a "before and after" shot, which is something I've found a bit strange, to be honest.

Despite that, the neurosurgeon was (perhaps unsurprisingly) keen to press on with endoscopic transsphenoidal surgery. The risks are largely the same as last time, although slightly increased as it's a second surgery. There's about a 15% chance that surgery will leave me with hypopituitarism - i.e. unable to produce one or more pituitary hormones. The most likely one to go would be thyroid stimulating hormone, as that's what the tumour produces, but it could be anything. Any hormone that I can't make would need replacing with medication (except possibly growth hormone, which they don't tend to replace unless strictly necessary), which I'd probably have to take permanently (although it depends; some people develop hormone deficiencies right after surgery and then recover). I'll be back on the steroids after the surgery until it's clear that my pituitary is producing ACTH (adrenocorticotropic hormone) again. Last time I was given a pill slicer when I left hospital, which I managed to lose, to my great regret - I'm secretly hoping I'll get another one.

There's also a slight risk of waking up with permanent double vision. The surgeon told me that he "can't remember" the last time this happened, but until I see a certificate assuring me that he doesn't have any kind of early-onset dementia, I refuse to be entirely reassured. It's because the tumour is now over to one side of the pituitary and surgery will thus be taking place closer to various important eye nervy things. I hope I'm not confusing you with all this technobabble.

It's a slightly different type of surgery I'll be having this time, endoscopic transsphenoidal surgery, which takes a bit longer but should have better results. I'll be under anaesthetic for longer, so probably will have more side effects from that and take longer to get over the anaesthetic. On the plus side though, they might not need to put packing in my nose afterwards, which would be awesome, because having the packing taken out last time was So Not Fun. However, I bled oozily from the nose for like three days last time and had to wear a hilarious moustache made out of bandages to catch all the blood (sorry for the TMI) for several days, so I guess I might be one of the unlucky cases who still needs packing. But oh my goodness, it would be nice not to have it.

Anyway, the whole consultation didn't take very long at all really, I couldn't think of any good questions, so I went home. The very next day, I was off to see the Ear Nose and Throat people... and have a tiny camera pushed up my nose. But more on that next time...

Hypoglycaemia time!

Had my first bout of post-lanreotide hypoglycaemia today. It's silly, you'd really think I would be used to handling it by now but it still catches me unawares now and again. Fortunately I had a delicious and nutritious dried fruit bar with me to help out, although it's not quite as good as Starburst. Mmm, Starburst.*

In other news, since having my Somatuline Autogel injection last wednesday I have been feeling rather better; I've been able to take fewer beta blockers because my heartrate has been a little slower, which has been reeeally nice - and also slightly surprising, because my heart is usually extremely slow to react to hormone changes, as far as I can tell. Plus it has been noticeably easier to go to sleep and to get up in the mornings which oh my goodness is seriously appreciated.

Also I was reading a newspaper article about the Olympics and I got a little teary-eyed, so I guess the "overemotional" aspect of these injections has also jumped in to play. People who know me in real life, you have been warned! Don't show me pictures of sad animals or I might drown you in my tears.
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* No, I'm not sponsored by Starburst. I'm just hoping if I mention them enough they'll take pity on me and send me some free Starburst.
Mmm, Starburst.

The Problem WIth Biliary Sludge

Good news at last! The lovely endocrine nurse at the hospital got it sorted and I had my Somatuline Autogel injection this afternoon. Hurrah! They still haven't worked out exactly how my next injection will be funded, but they've got four weeks to do so, and I'm already booked in for the next appointment so I will be turning up expecting it to be very much All Sorted Out by then.

The lanreotide injections do have a bunch of possible side effects, my nurse gave me the list. It is a long list so I just picked a few of my favourites:

- biliary dilatation (don't know what that is but it sounds unpleasant)
- alopecia (because so far my hair just hasn't been falling out enough)
- sinus bradycardia a.k.a. slow heartbeat (YES PLEASE)
- general physical weakness (as compared to my usual muscular state)

I've had these lanreotide injections before, so I know that for me they usually make me nauseous for the first couple of days. Then after that they tend to make me quite prone to bouts of hypoglycaemia so I have to carry around sugary things (usually I'm bad and carry sweets but this time I have invested in some tasty dried fruit). Some people get gallstones and diarrhoea and headaches and all sorts so I guess I am fairly lucky.

I was chatting to my endocrinologist about going back on the injections and he asked if I had any bad side effects so I explained the above and said that the last time I went on the injections I read online that eating an extremely low fat diet for the first few days after having an injection can help reduce side effects, and that since doing so I found I didn't get so nauseated.

I also mentioned how the first time I had them, I was led to expect they would be so awful that it was actually kind of a pleasant surprise just to feel sick for a few days. But obviously they had to tell everyone it might be as bad as the worst case scenario, just in case.

He nodded sagely and said, "Ah yes, the old biliary sludge problem."

I had no idea what he was talking about, although it did occur to me that Biliary Sludge sounds like the name of a character from Dickens.*

Maybe that's just me.

As it goes, it turns out that biliary sludge is the precursor to developing gallstones if you're on this medication, it's like lots of teeny gallstones which build up and slosh around in the pancreas. It's caused by a low turnover of bile in the pancreas (which this medication can cause) and it can be improved by eating a low fat diet. But you're much more at risk if you're overweight or obese, so hopefully I should be fine.

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*He would have many jowls, and a faded red velvet coat, and his whiskers would be full of yesterday's dinner.

IMFW: Face Transplants

Today's Interesting Medical Fact of the Week is all about face transplants! Recently an American man named Richard Lee Norris received what is allegedly the most extensive face transplant ever carried out, in which he received a new jaw, teeth, tongue and nose. The pictures are pretty incredible. After being severely disfigured by a gun accident, Mr Norris had been living as a recluse for fifteen years, wearing a mask whenever he had to leave home - and he had lost his sense of smell completely. That's all changed.

Only the 23rd facial transplant ever carried out, the operation was a gruelling 36 hours long; all Mr Norris' facial tissue from the scalp to the back of the neck was completely replaced. As with every transplant, there is a risk of rejection; recipients of face transplants have to take immunosuppressant drugs for the rest of their life, which increase their risk of cancer and infection. The first Chinese recipient of a partial facial transplant, Li Guoxing, died in 2008 just two years after his transplant, when he either stopped taking his immunosuppressant drugs or failed to take them correctly. There is also the potential psychological issue of patients finding it difficult to adjust to their new face; although such transplants don't give the recipient the face of the donor, nevertheless even after the most successful operation they will never regain their appearance from before their injury.

The world's first face transplant came in 2005 in France, on Isabelle Dinoire, whose face was so badly mauled in a dog attack that she was left unable to speak or eat. Dinoire has had problems with her transplant, including kidney failure and two episodes in which her body tried to reject the transplant. But from the interviews she's given, it seems that she has been happy with the results. The first full facial transplant came in March 2010, when a Spanish man who had accidentally shot himself in the face received a completely new jaw, nose, teeth, cheekbones and skin.

Face transplants can be controversial because some people see them as being done for "cosmetic", rather than purely medical reasons. Yet if you look at the people who have received facial transplants, it's clear that in every case their disfigurement affects their lives in much more than a purely "cosmetic" way. These are people so badly injured that they can no longer eat, drink, or - in some cases - breathe independently. For them, the risk of rejection and of a shortened lifespan due to the immunosuppressant drugs is worth taking in order to have the chance to live a more normal life.

Equally, as the story of Richard Lee Norris shows, even for those who remain independent after injury, the effects of severe facial disfigurement are much more wide-reaching than the purely medical, affecting employment, relationships and simply the ability to leave the house without feeling the need to cover your face. It's difficult for those of us who haven't experienced disfigurement to understand just how significant an impact it can have on people's lives. Obviously, face transplantation is an extreme step and certainly not one which is suitable for most people with serious disfigurement - but it should be available as a last option for those who cannot be treated by other means.

Some doctors have raised concerns over the way these transplants are followed up, suggesting that there should be greater emphasis on psychological analysis of patients, to gain deeper understanding of just how facial transplants affect recipients.

Connie Culp, the first US recipient of a face transplant.

The Guardian has a short history of face transplants here.

Travel to Mars, deform your pituitary gland...

Todays papers have been awash with the news that astronauts may suffer side effects from spending long periods of time in space; specifically, their eyesight may be damaged due to effects which appear similar to intracranial hypertension; i.e. increased pressure in the head. Their eyeballs have literally changed shape, making them more longsighted - which, in the case of those astronauts who started off with short sight, has actually improved their vision.

In pituitary-relevant news (which this blog is always excited about), doctors examined 27 astronauts who each had a cumulative total of at least 30 days in space, and of those 27, three were found to have slightly deformed pituitary glands. I have struggled to find any more details on exactly how their pituitaries were "slightly deformed"; I presume that their pituitary glands may have become somewhat flattened along the interior walls of the sella turcica cavity. And although that sounds suspiciously precise coming from me, I promise I'm not making shit up; that's what happens in primary empty sella syndrome, which can be a sign of intracranial hypertension.

Shit, where'd I leave my glasses?

I Want Acromegaly

As many of you are no doubt aware, I'm the kind of sad and tragic person who has enough time in her life to trawl the internet for other blogs about pituitary adenomas. Due to a weird and extremely irritating Blogger glitch, I'm unable to follow anyone anymore, but I still seek them out.

And two separate sites I found today, both about acromegaly, got me thinking. They got me thinking so much that I suspect I'll have to split my thoughts out across a couple of posts, or risk literally boring my readers to death.

The first was this: a conversation on a forum begun by a guy who claims to want to have acromegaly.

Quick recap: Acromegaly is a serious illness caused by a rare brain tumour on the pituitary gland which releases growth hormone into the blood. It can cause uncontrolled growth throughout the body, especially the hands, feet, chin, nose, tongue and forehead. It can also cause impotence, congestive heart failure, kidney failure, diabetes, loss of vision, and death. It is a devastating diagnosis for those unlucky enough to have it.

I quote:

"I really want to have this condition. I want it because I have a "babyish" face and my facial bones are not as developed as they should be. I'd rather not get cosmetic surgeries such as chin impants and jaw implants. When my face becomes as masculine as I want it to be I'll just get treatment for it.

Also my hands are small for a mans and I'd like to have bigger hands.

[...] How can I induce acromegaly in my body? Is it even possible?"

This guy may be a genuine idiot, or he may be a troll, but the fact is that there really are people fuckwits out there who inject themselves with growth hormone because they think it will make them better at sports/bodybuilding.* These people are effectively giving themselves mild acromegaly, despite the fact that there is really very little evidence that it could improve sporting performance, and it may actually decrease stamina despite increasing muscle mass.

Those of us cursed with epic fail bodies that go haywire at the slightest provocation tend to strongly resent it when fit and healthy people take risks with their health and fitness for the purpose of vanity. When I was having the packing removed from my nose after my brain surgery, and it was incredibly painful and there was blood everywhere,** the first thought that went through my head was: "Why would anyone ever have a nose job by choice?" (Plus, as a person who regularly has health professionals sticking needles in me, I can't get my head around someone actually volunteering for human pincushion duty).

Going around saying that you want to have acromegaly to gain a better jawline is like saying you want to get cancer so you can lose weight. Not only is it incredibly disrespectful to those people who seriously suffer with a horrible illness, it's just incredibly stupid. Injecting yourself with growth hormone so you can stand on a stage with a bunch of other people and flex your muscles impressively... words fail me. Not only are you putting your body and your health at risk, but you're cheating. All the other hard work you did to get those muscles is wiped out. You didn't win because you happen to be the muscly guy who worked the hardest and had the best muscly genetics out of all the hardworking muscly guys with muscly genes; you won because YOU'RE A DUMBASS.

Actually got surprisingly angry writing this! My next post on the topic of acromegaly, Cushing's disease, and physical appearance is coming soon...

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*I recommend clicking on that link and scrolling down to the photo of the incredibly muscular man cuddling his pillow with his giant melon-packed arms, it's hilarious.

**In fairness, apparently it's not usually as bad as that, I just have a particularly objectionable nose. If you're squeamish, don't continue reading: The first time the nurse tried to pull the packing out, I asked "How badly will it hurt?" and the nurse replied "A bit." I am fairly good at dealing with pain usually, so I braced myself. She gave the packing a firm nug and it felt like my nose had exploded. I shrieked and she gave me a slightly unsympathetic look and told me I had to "get it over with". On the second attempt, she got the packing out, along with really quite a surprising gush of blood that went all over the floor. It hurt so much I was physically shaking and the nurse was forced to admit that it wasn't usually quite so horrendous.

IMFW: Aluminium Does What Now?

Today's Interesting Medical Fact of the Week is dedicated to my lovely boyfriend. No, he doesn't have a weird and unusual illness, or even just a particularly hilarious deformity - but he does have a deodorant made from Japanese sea minerals.

"What are Japanese sea minerals?" I said.
"I don't know," he said. "But it doesn't have aluminium in."
"Do deodorants normally have aluminium in?" I asked, exposing my ignorance.
"Yes," he said. "It gives you cancer."

At that point, my brain practically exploded and I resolved to investigate whether or not he was just winding me up. And thus, my next Interesting Medical Fact was born.

As it turns out, aluminium is a common ingredient in anti-perspirants rather than simply deodorants. But here's the thing: it can be absorbed through the skin, and it's been suggested that there may be a link between use of such products and the development of breast cancer. The short story is that there's no conclusive evidence for a link between antiperspirant use and breast cancer.

Looking at Wikipedia, though, it's not just cancer you have to be worried about if too much aluminium gets into your system. It's a neurotoxin, high levels of aluminium are present in the brains of many Alzheimer's patients - and one study linked the long-term use of antiperspirants containing aluminium with the accumulation of levels of alumium that may increase the risk of Alzheimer's disease. The good news, however, is that a causal relationship between aluminium and Alzheimer's has not been found.

Finally, the only concrete evidence for these antperspirants adversely affecting your health: renal dysfunction. No, aluminium doesn't cause it, but people with renal dysfunction are advised to consult their doctor before using deodorants which contain aluminium. Damaged kidneys cannot clear aluminium from your body as effectively, and thus patients with kidney failure may be at increased risk of building up potentially dangerous levels of aluminium in their systems.

Of course, the fact that no proof has yet been found doesn't mean that no proof will be found for a link between aluminium anti-perspirants and cancer or Alzheimers. But for the time being, they are officially considered safe.

Side Effects of Lanreotide Injections

Long time no post! Regular readers will no doubt be waiting, almost breathless with excitement, to find out how my lanreotide injection on Monday went. Did I get a nice nurse? Did she remember to leave the syringe out of the fridge beforehand? Did I spend the next two days feeling nauseous? Will I find something more exciting to write about?

Long story short: yes; yes; no; find out next week in another exciting installment of Pituitary Ademoaner: The Blog!

In any case, the lanreotide has been rushing around my system for a few days. I fondly imagine it coursing through my veins, up to the pituitary gland, and beating my pituitary adenoma around the head, shouting "Stop it! Stop it now! Bad pituitary!" much like a miniature Punch and Judy show without the part about the crocodile and sausages.

I don't have a list of the side effects of Somatuline lanreotide injections, although I seem to remember that they are many and hideous. I'm pretty sure gallstones and feeling sick are the major issues.

But medicines should have side effects; it's only right and proper. I'm pretty sure that if I ever opened a packet of pills, opened up the little leaflet inside* and found that the list of potential side effects included neither coma nor death, I would hardly consider it medication at all. This is just one of the reasons I mistrust homeopathy. If it can't kill you, I refuse to believe it can cure you, either.**

So I present my personal list of the potential side effects of lanreotide injections, which I scarcely need say is not an official list and may in fact be completely fictitious:

Side Effects of Lanreotide:

1. Making you walk like an international rap star after the third drive-by caused permanent nerve damage.***
Big old needle right into hip (or, in fact, into right hip). It's painful while it's happening, but in fact it's worse when you're on the long walk home in jeans which irritate the skin where you've just had the injection.
Option 1: limp like a pro.
Option 2: wear your trousers around your knees.
Put them together and what have you got? A multi-platinum record deal.

2. Exposing the folly of your healthcare providers.
One of the biggest side-effects of lanreotide is that it upsets your stomach and makes you feel nauseous. I had this side effect after every injection last year; after the first one, I felt pretty unwell for several days. Various doctors and nurses warned me about it, saying that lanreotide affects everyone differently, and you simply had to wait it out.
This year, I read on the Pituitary Society's forums that several people who have regular lanreotide injections for acromegaly had been told by their endocrinologists to eat a very low-fat diet for the first few days after the injection, in order to prevent the nausea. So I thought I'd try it, spent the next two days eating vegetable soup and sushi, and hey presto: zero stomach pain and only very very mild nausea a few hours after the injection. If only I had known last year!

3. Itchy Hip Syndrome.
A serious condition, usually associated with insect bites, poison ivy, and low-quality undergarments. I don't know if it's just me or if this happens to everyone, but oh my god my hip is so itchy it's like I survived an attack by a killer mosquito.
At the injection site, not just randomly. That really would be weird.

4. Sudden and complete IT systems collapse.
Almost immediately after I had my injection, the servers at my place of work crashed catastrophically, leaving me unable to log on for about six hours. Coincidence? I THINK NOT.

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*You must always read the little white leaflet.

**Of course, I'm exagerrating. Homeopathic treatments do come with side effects, such as inadvertent emptying of both the pockets and the brain.

***And/or with a limp like an old school pimp.