Thursday, March 29, 2007

MGB vs. RNY vs. Cigna

As we find more about the various gastric bypass surgeries, and the varying and often draconian requirements various surgeons and facilities require, we keep shifting which are our greatest concerns.

The most recent one was that there was a 350-pound limit on all the laparoscopic versions; having to go to an open surgery increases the risk considerably (as well as the recovery time), and it seemed likely I wouldn't go ahead with it if it had to be open, though it's too early to make that decision. Nor was I very positive about the idea of finding a way to lose 130 pounds without any help just to get to the point where I could get the surgery; maybe I could do it, maybe not, but at best it'd mean being miserable for a very long time just to get to the surgery.

However, we've learned that High Point Regional Health System in North Carolina does MGBs (which are always laparoscopic) up to 450 pounds, which is well within reach for me.

The question of finances still looms. While our doctor is confident that we can get this kind of surgery covered, it's quite likely High Point is an "out of plan" facility. There's some very, very, very small chance that we could get it covered anyway if it's only available for us there, but more than likely we'd have to treat it as an out-of-plan facility. That would mean a $2,500 cost to us for each surgery, plus figuring out how to cover the whole $17,000 cost in between the surgery and getting it paid, since the doctors wouldn't bill directly. Financial problems are a factor but not a showstopper; our credit rating ensures that we can deal with these kinds of concerns, even if it's hard, costly, and stressful.

On a more positive front, I'm feeling very strong that I meet the selection criteria for these procedures, and won't have too much trouble convincing the doctors to let me do it. MGB is continuing to look like the best option, as I read more about it and its results, but I'm still keeping an ear out for someone trash-talking it with actual results, not just vague dislike and anecdotal considerations. I'm sure there are facts to be had out there, but it's troubling how much conjecture and bias there is. This is medicine, folks, and medicine is a science.

Wednesday, March 21, 2007

Gastric Bypass, Step 2

Yesterday we visited our doctor -- or as close as possible, since our previous doctor moved away and no new one has been hired for her patients yet, so a physician's assistant is handling us until a new doctor is brought on. The PA was very encouraging about the possibility of a gastric bypass. She didn't think there'd be any trouble getting insurance to consider it a medical necessity (at least, no more trouble than anything involving insurance), and she seemed little worried about the dieting requirements, considering we have 4½ years on record already. Maybe she's being a little excessively positive on that last point; I suspect the surgeons will make us jump through pointless hoops, but nothing we can't do.

Step 3 will be talking to surgeons. We got a referral for a consultation at Fletcher Allen, where we will talk to someone, probably a surgeon, about the options and what comes next, and assuming we decide to proceed (which seems likely at this point), how it'll go.

The big question still hanging in the air is whether to go for laparoscopic Roux-en-Y (of the various bariatric surgeries that are shown to reverse diabetes, this is the most common and well-known) or the Mini-Gastric Bypass (MGB). A lot of our research has showed lower complication rates and lower risk from MGB, so we've been leaning towards that, despite far greater difficulty arranging it (due to it being available only far away, the probability of far greater difficulty with insurance covering it, and the question of how to finance it).

However, we're starting to uncover some evidence contradicting that, and speculating that some complications are not being accurately recorded, because of the unusual nature of how MGBs are done (only by a few "licensed" surgeons) means some complications might be handled at different hospitals and not connected back up to the original surgeries in reviews of post-operative results.

Nothing we've found so far is truly conclusive. The most damning criticism of MGB seems to be that there have not been any truly comprehensive comparative studies contrasting it with Roux-en-Y; Dr. Rutledge, the inventory of MGB, claims that this is true only because Roux-en-Y practitioners refuse to cooperate in such a study.

And this is typical of what we've found so far; generally when you hear physicians talking about these surgeries, you get the feeling that you're hearing their personal preferences and prejudices at least as much as you're hearing the science. Personal preference and prejudice is supposed to be the patient's job in the doctor-patient relationship; the doctor is supposed to be the one dragging the patient away from spurious reasoning to scientifically-backed results.

Hopefully when we sit down with a surgeon up at Fletcher Allen we'll be able to dig through all of this. We're trying to keep open-minded about the procedures, willing to listen to the surgeon's input while at the same time insisting it be substantiated and scientific, rather than being focused on how what they happen to do at that hospital is inevitably the best treatment. ("As far as this case is concerned I have now had time to think it over and I can strongly recommend a course of leeches.")

Monday, March 12, 2007

The final death knell of Harshlands

Today I did my weekly login to Harshlands. I don't go in to roleplay or participate anymore; all I do is keep my cart stocked for the benefit of those players who use it as part of the Tashal economy, while slowly accruing silver I will need if they ever make caravanning possible.

But I don't really play. No, I stopped that a couple of months ago, as I wrote about in the blog. There were a number of reasons. A lot of them were flaws in the game, in what it was trying to do versus what the admins were willing to let it do. Some were based on the simple unprofessionalism of the admins, my exposure to which all ran back to one act of twinkery that went unpunished and almost ruined my character last year -- that act wasn't the real issue, though, it was the hostility that it engendered in the admins towards me. I continued to pour my soul into the game, doing lots of in-character development, plus serving as a volunteer coder, hoping that one day they'd make good on their promises to make caravanning work, and hoping that the other problems could be worked around or lived with. But instead, caravanning got less viable as time went on. Most of the people I enjoyed playing with left, or had their characters die and recreated in other places, or went dormant, or simply got themselves involved in things that prevented my character from running into them. Playing got to be no fun. But I stuck it out for months until I finally stepped away... announcing I would keep my cart stocked and be ready to caravan if it ever got viable.

So today I went to stock my cart to find that it had been robbed. Again. Now, this might not seem too odd, but you have to understand the situation. It's a two-wheeled peddler's cart; there's not really room to be on it, let alone hidden inside it, and it only has "interior" rooms because of OOC code limitations -- that's how the stockroom is handled. Here's a similar cart, only much larger because it's four-wheeled:

Bolted to the cart is a sturdy wooden strongbox with a hefty lock. Inside that is a sturdy chest with a lock. There's another locked area where the goods are kept (and where revenue is stored).

The cart is smack dab in the middle of the busiest square in the entire island. The room description specifically says that the square is crowded shoulder-to-shoulder even in the middle of the night, and that the whole square is brightly illuminated with lanterns. There are several guards posted there, in addition to the peddler who works the cart.

Months ago, while my character was a struggling journeyman trying to close the gap between the incredibly poor income rate of a peddler (mostly caused by game limitations) and the huge startup costs of a caravanner, his life savings was robbed from that chest. The admins explained away this impossible act by claiming that it was done at a time when the square was emptied due to an unprecedent invasion of undead. Fair enough, except that I read about that invasion hours before it happened. Trouble is I can't prove that. The admins never admitted, and still do not admit, that there was twinkery involved -- which is funny because the players involved have admitted it was twinkish. And based on that it was handled IC, including my character paying 3000 silver (a large fortune) for lifelong protection against further robbery.

Today, he was robbed again. This time, all three locks were picked, and it's probable merchandise was also taken (no way to tell -- either it sold and the silver from the sale was taken, or it was taken, or some of both).

Now, the important thing which will escape most people's attention is that this isn't about the robbery or the silver. As I write this, the issue of whether this is a twink remains to be decided, and if it is, I might get the silver back. I can't say I'm terribly optimistic given how badly this was handled last time. And yet, the last time might force them to handle it better this time, since they got caught screwing up last time and then refusing to admit their mistake and digging themselves in deeper, so they're extra defensive now. But it doesn't matter.

See, it turns out that the responses I got to my petitions were insulting in a way that defies even my low expectations. It's so far into childish it might be intentionally playful in a way that went very wrong, but even if you grant every possible benefit of the doubt, it still ends up painfully insulting. Amongst the more infuriating insults concerns my use of OOC rather than IC methods to deal with this and everything else -- a clear suggestion that I don't count since I no longer roleplay:
And if not well that is sort of something not
to handle in character.
No, would probably be something out of character.
Best to come in and not play really.
Just use the mechanics.
And stuff like that.
And when stuff does not work fix it.
And go on using the mechanics.
Would really be better that way.
No tension of roleplay and stuff.
And no in character out of character seperation needs.
For all would be out of character.
Another good idea.
Of all the people to be snarky to about handling things IC and contributing to the game, they are so completely off-base to pick me. Plus they deleted the post I made on the forum about it. So what do you think the odds are that they're ever going to feel like treating me fairly, live up to their promises, and make me welcome in the game again?

A tiny part of me wants to note that I still have coder access to their box and could cause an essentially unlimited amount of harm to the game if I wanted. Luckily for them I'm very much not the vindictive sort; this post is about the meanest thing it's in me to do, and that's mostly wanting things to be aired. Besides, I would never punish the other players; they're suffering enough as it is, and if anything I want to find ways to make things better for them on the way out. (The tiny part wonders if crashing the game might not make things better for them, though; maybe being forced out of the game is the best thing for them.)

I am currently "closing up shop" in the game so that my character's departure is explained, and his assets are used to at least benefit those who remain behind, continuing what little I was able to do to add to the game for the benefit of other players. It's frustrating and angering, and yet at the same time, it's almost a relief to close the door on this chapter finally.

Though when I say "finally" I must admit that I have made provisions to undo this departure in the extremely remote possibility that things change. In the short term, that'd mean them changing their tune and coming back with a very convincing apology. If that happened (and just after monkeys flew out of my butt) I'd be able to undo my departure with minimal IC explanation needed. In the longer term, if they stepped down as admins, in favor of someone with more professionalism, I could probably explain my character's return and start afresh.

But these are both very remote possibilities. They don't feel like not closing the door, just like the chance a new door could maybe be opened someday, but not likely. I still get the sense of closure.

Friday, March 09, 2007

The subject is not the first line

I was tempted to make the title of this blog post be "Did you ever notice how..." After all, how often have you seen an email, forum or newsgroup post, blog post, etc. where the subject was something like that?

There's a reason we have a subject field separate from the body of the message. The subject or title should summarize what the body is about. Having it in a separate place enables the reader to find the items of interest to him. It allows focused searches, effective threading, and indexing of entries. Imagine what a visit to your library's card catalog would be if every book's title was just the first five words of the book!

When you simply dump the first few words of the body into the subject, you're defeating the purpose of both. You're making it harder for me to read whatever collection of messages or items your entry is in: a forum, my email inbox, a blog, whatever. And that means you're making it less likely that I'll read yours.

So use the subject or title to record the subject or title of your post, okay?

Thursday, March 08, 2007

But I want to want those things!

The ideal outcome of a hypothetical weight reduction regimen would be this: I would still want and enjoy and eat all the same foods I do now, but I would be satisfied -- genuinely satisfied -- with smaller amounts, and those amounts would allow me to lose weight and end up healthier.

But what about something where the net result of the procedure was that I no longer even wanted or liked some things I now like?

Obviously, after the procedure I wouldn't miss those things, any more than right now I miss brussel sprouts or pickles. I would be perfectly content. And people who have had gastric bypass and found that formerly-loved foods are no longer desirable tend to insist that they're glad they did it; they have no regrets.

Yet the me now can't help rebel at the idea. I get so much pleasure from, say, a good New York bagel slathered with cream cheese. A surgery that made me like only a small portion of that, that'd be fine; I'd still have the same enjoyment followed by the same satisfaction. But a surgery that left me no longer desiring it in the first place... I can't help feel like I'd be losing something. The pleasure I get now from that bagel would be simply gone, with nothing to replace it.

Any argument that a post-op person gives to defuse this "concern" feels hollow: it has the ring of someone who has lost something and lost the ability to know he lost it. I don't mean to sound overdramatic, but it sounds like someone who's been brainwashed. One can't help imagining that if a later surgical development restored to them the ability to enjoy those dishes they've said goodbye to, they'd be the first to say "thank heavens, I had forgotten what I was missing!"

I can't help imagine someday a better version of the surgery coming along that is like what I originally described: you like the same things, just less of them. And those people who have already had today's surgeries will not be able to "upgrade" (and may be so "brainwashed" that they don't think they want to).

And yet, the people who've had the surgeries almost all agree that they don't regret giving up those things. And so too would I not regret them if I had the surgery. Is it foolish, petty, and self-defeating to be even concerned about it now?

Monday, March 05, 2007

Gastric bypass surgery

This weekend I had a small job I picked up through RentACoder to record a TV show and do a transcript of the show, which entailed watching it several times. The show is called Action Hero Makeover, and it turns out it's about a relatively new variation on gastric bypass ("stomach stapling") surgery, as it was performed on Gil Gerard.

If you don't know me, you should know that I'm extremely obese, with a BMI in the 75 range. Most of the typical complications and correlated illnesses, however, have not been a problem for me. I've never had high blood pressure, and my cholesterol has generally ranged from acceptable to very good (with the exception of HDL which I just can't get to go up). I've shown no signs of heart disease.

In recent years I've been diagnosed with type II diabetes. However, I've also shown that it's possible for me to control it, even without meds. I've also shown that I can fail to stay in control. This progressive failure is mostly because of my own failures of willpower, but it's certainly true that my weight contributes: it's hard to be active and exercise when my weight itself is an obstacle so often, in the form of knee pain and general soreness at even modest activity, the difficulty of getting started, the cost of equipment that can hold up to me, and the general low level of energy I have.

Generally speaking I believe that it's possible to be "fit and fat", and that the medical community has assisted in perpetrating a number of fallacious ideas about overweight, the most pernicious being that if there are poor health conditions associated with overweight, that losing weight is invariably a means to solve them.
  • First, correlation in the public at large doesn't mean correlation in any individual; for instance, my lack of blood pressure problems at my size is unusual, but it doesn't hint at a hidden problem.
  • Second, correlation isn't causation; many of the ill effects associated with overweight are effects of a common cause, not effects of overweight itself, and trying to prevent them by eliminating overweight can be like trying to avoid sickle-cell anemia by bleaching your skin.
  • Third, even when a health problem can be reduced or eliminated by losing weight, that doesn't always mean the health effects of attempting to do so aren't worse. Though rarely publicized, the ill effects of almost all forms of dieting are well-proven, and it's clear that dieting is not only rarely effective but usually counterproductive.
That said, I wouldn't mind not being fat one bit. There are lifestyle reasons; one feels petty talking about the thousand discomforts of being in a world that refuses to fit me, and one feels like arguing with the world and insisting it accomodate me rather than "giving up" and adjusting to fit it, but despite that, it'd sure be nice to be able to fit on planes and in cars, not have to apologize every time I try to pass someone in a restaurant, and be able to buy clothes cheap and easy. And there are health reasons like back and knee pains I wouldn't mind missing.

But the best reason is to be rid of diabetes. Yes, rid of diabetes. This is something I've really thought of as impossible, and that's what really struck me about that show I was transcribing from. Before the surgery, Gil was a very out-of-control diabetic, with fasting blood glucose numbers in the 300 range; we weren't told if he was doing anything to treat it, and it's possible he wasn't because other, more serious health concerns he was dealing with would preclude most forms of treatment. After the surgery, his fasting blood glucose was in the 100 range -- entirely normal, with no diabetes treatment at all. It's commonly said that once you're diagnosed diabetic you can only be "in control" or "out of control" but you can't ever not be diabetic, but even the doctors described Gil unequivocally as no longer diabetic.

I've known about variations on "stomach stapling" for years, but they were very dangerous and not terribly effective. Before I was diagnosed diabetic, I didn't give them much thought; clearly they were a lot of risk to solve not very much. (It didn't help that my father died on the table in exactly this kind of procedure; though it probably didn't hurt as much as you might think, given that my father was never very close to me, and that I am not the kind to obsess and worry and get wrapped up in fear because of something like that.)

Even after my diagnosis, I still didn't think much about them because they still seemed too risky, and I didn't think they'd make that big a difference: maybe they'd cure the discomfort of airplane seats, but not diabetes. I always had a general sense that one day the risk would be reduced to near nil, the efficacy improved to highly reliable, and the option would become far more accessible; and then I'd have to re-evaluate. But I didn't think that day was anywhere near yet.

The show made me wonder if maybe the time is nearing after all. Dr. Rutledge's technique, Mini-Gastic Bypass (MGB), offers some very compelling advantages even over the "state of the art" techniques now being done all over the country. The risk of dying on the table is now comparable to everyday surgeries like appendectomies. Other complications are very rare for the most common procedures, but for MGB they're far lower still, almost negligible. MGB also costs a good deal less, since it's a laparoscopic technique with a recovery time measured in hours, not weeks. I'm not just reciting the TV show's points; most of these comparisions between MGB and other bariatric procedures weren't mentioned in the show. But I've been doing a bunch of reading, and MGB simply becomes a more compelling option the more I read. Not merely by comparison to other bariatric surgery options, but more generally, as something that maybe I should seriously considering doing.

However, there are two big snags.
  • Requirements: All forms of bariatric surgery require you to demonstrate extensively to the surgeons that you have spent years and years sincerely trying other methods of losing weight, and failing. While I have done "diet and exercise" for years, and it's easy to show I haven't lost weight and kept it off, I would have to lie to suggest I was trying to lose weight. Apart from the discomforts like back pain and difficulty finding clothes that fit, I haven't minded my weight; it's my diabetes I have minded, and I found that my control over that and my weight were barely correlated, if they were correlated at all. I did lose weight during my "in control" years even though I wasn't really trying to; but sometimes I gained it back, and my control didn't track my weight really at all. Would my attitude towards my weight be considered by the surgeons and therapists to be "unhealthy"? Would they refuse to consider me because I hadn't tortured myself enough with diets and done enough damage to myself before coming to them? Maybe I could parley my struggle with diabetes into something, but I'm doubting that could really live up to the kind of onerous requirements I'm seeing.

  • Insurance: It'd be easy to prove to an insurance company that, if someone's going to be on their insurance for a long time, it'll make far, far more sense in the long run to let them get surgery like this than to wait for insurance to have to pay for the ongoing treatment of a chronic problem like diabetes, then deal with the complications. It's a no-brainer: $17,000 now versus tens, hundreds of thousands, maybe millions over the course of a life. But what's this, logic, in a paragraph that started with the word "Insurance"? What was I thinking? No doubt the insurance company is hoping that my employer will change insurance companies before then, or failing that, that I'll be hit by a bus. Or perhaps they still think that everyone who is overweight is so because they're evil. Either way, they don't cover procedures like this. Could one wangle an exception based on "medical necessity"? Uncertain. But given how it took months of stress-inducing, health-eroding arguing with them just to cover a better blood sugar meter, one can't help wonder if the cost they'd exact in sheer agony wouldn't make surgery seem like recreation by comparison. This is a doubly interesting question to ask right now since our long-time primary care physician is moving away, so we don't even know who our new doctor is yet. Who knows how sie will feel about us? Or how good sie will be at dealing with the insurance company, even if sie decides this is worth fighting for?
Yet through all of this haze, the image keeps haunting me of the idea of not being diabetic anymore. If this is going to happen, there's a lot of thinking, research, planning, struggle, and perhaps outright fighting, and a lot of time, in between me and it. I guess maybe it's time to start preparing to start prepare to decide whether I'm going to start preparing to do it. Maybe.

Thursday, March 01, 2007

Poor Odysseus

After several years of wandering aimlessly around my house getting into messes, Odysseus, our Roomba Discovery, has found his way back to his charging base for the last time. iRobot made me wait two weeks for a firmware upgrade that didn't help, as I knew it wouldn't -- you can't fix hardware problems by updating software. Now they are willing to do an out-of-warranty exchange for $95 which gets me a fresh new (or at least refurbished) Roomba Discovery, while Odysseus probably gets refurbished too.

Meanwhile, Telemachus, our Roomba Dirt Dog, is filling in best he can for his dad. Telemachus is made primarily for basements, workshops, garages, and decks, and has no vacuum, only sweeping. He's not nearly as good as his dad is at doing the floors. But he does well enough that Penelope, the Scooba, can mop them effectively. It gets the job done, but I am really looking forward to having a proper Roomba again.

If Odysseus is gone, what should his successor be named? It's tempting to keep the name, since it's so appropriate, and since the replacement will be identical and a refurb besides, so is it really different from if he were sent off to be fixed? Besides, using the name of one of his suitors (probably Antinous) just seems too bleak.

But then the perfect solution occurred to me: Aethon, the name Odysseus affected while he was disguised as a beggar. So it won't be him, but maybe it still will...