Shelby Goes Under the Knife (Again)

On Wednesday, February 7, I will go back under the knife, although this time it's planned.

Shelby's Sleep Apnea

If you've ever shared a room with me (as many of you have), the fact that I have sleep apnea should come as no surprise. I've always snored like a lumberjack, not to mention gasping for air in my sleep. I've also been able to hold phone conversations while fully asleep, but that's different :). Sleep apnea, or more formally Obstructive Sleep Apnea Syndrome (OSAS), is a medical condition in which a person stops breathing (an apnic episode) for at least 10 seconds several times throughout the night. When a person stops breathing, a deeper primitive reflex kicks in and wakes the person to a level at which breathing is restored. The result is that the person never gets a full night's sleep, as they are constantly waking in order to breathe. Daytime fatigue, snoring, and depression are some of the many symptoms of sleep apnea.

Getting Diagnosed

To get a diagnosis, I had to undergo a sleep study at the Stanford University sleep center. I spent the night at the sleep clinic with around 40 small wires glued to my head, face, chest, and legs. My sleep study showed that I do indeed have sleep apnea. In fact, my longest period of uninterrupted sleep was 9 minutes. That means instead of sleeping for 7-8 hours like normal people, I take a series of 9 minute naps all night. No wonder I'm worn out during the day!

Where's the Obstruction?

Armed with my sleep study, I then made an appointment with a doctor at the Facial Reconstructive Surgical Group (in the happy team picture, my guy is the third from the left). Despite their odd practice name, this group of Stanford-affiliated doctors actually pioneered most of the treatments for sleep apnea available today. In order to examine my airway, the doctor took a side X-ray of my head, and peered down my nose with a fiber optic scope (that was a bit strange). Turns out I have a number of problems. First, I have a deviated septum, which makes my nose crooked and blocks a lot of my nasal passage. Then, I have huge adenoids. But those aren't the major problems. My soft palate and uvula (that dangling thingy in the back of your throat) are quite large, and when the muscles in my mouth relax, they fall back and block my airway. I've also got big tonsils (see adenoids). And finally, I apparently have a monster-huge tongue. Who knew? When you are awake and sitting up, there is supposed to be between 11 and 13 cm of space between the back of your tongue and the back of your throat. At my best, I have only 3 cm. So when I fall asleep, well the tongue blocks my airway that there it is.

What is Surgery Going to do?

It's been over a year since my first sleep-related appointment, but finally I've got insurance approval and am headed into surgery. First, I get a uvulopalatopharyngeoplasty (UPPP). Say THAT five times fast! Basically, they're removing my dangling thingy. Then comes the difficult surgery...the Genioglossus Tongue Advancement (click on genioglossus tongue advancement). For the morbidly curious among you, this surgery basically entails cutting into my lower jawbone where the tongue base attaches, pulling that forward, twisting it 90 degrees, and screwing it back into my jawbone. Should be fun!!!

Recovery?

I'll be out of work for two weeks, and on a liquid diet for at least that long. I won't be able to talk for at least a week. I think everyone is pretty happy about that.

So in a nutshell, that's my latest round of surgery. Hopefully after all of the swelling has gone down, I will be breathing freely, and we'll all get a good night's sleep.

Unfortunately, this surgery will not address the issue of me stealing the covers.

Want to know more about sleep apnea or think you might have it to? This website is a great place to start.

A Happy Ending

It's been almost 4 months post-op and I'm happy to say that the surgery was a resounding success! I no longer snore (now Scout is the loudest sleeper in the room) and I feel much less tired during the day and can actually get up in the morning. Other people do this? Who knew?

During the surgery, there was a slight change in plans. While I was scheduled for the genioglossus advancement, where the doctor cuts a "window" of bone and advances the muscle, it turned out that my mouth/jaw was too small for this procedure. Instead, I had a sliding genioplasty. Usually performed for cosmetic purposes, the sliding genioplasty involves cutting the tip of the chin, moving it forward, and fixing it in place with titanium screws. It's difficult to describe but you can see some pictures here. The effect this has on sleep apnea is that the base of the tongue muscle attaches at the chin, so moving the chin forward advances the muscle and flattens out the back of the tongue.

No, my tongue does not stick out now :). The tongue actually continues far into your throat, and it takes a sharp turn at the back of your mouth (open your mouth--look in the mirror--see where your tongue "ends"? That's where it bends down into the throat). During an apnic episode, the relaxed tongue falls backwards into the throat, blocking the airway. The top part of the tongue (the part you can see), the back of the tongue, and the genioglossus muscle form a triangle shape (except the tip of the tongue and the muscle don't actually meet). Moving the muscle forward pulls on the back part of the tongue, moving it forward as well, without affecting the top part of the tongue.

The result is a greatly improved airway, and a new chin look for Shelby! My chin was advanced about 6 centimeters. The visual change is minimal (well, I can tell, but most people can't) and is most obvious when looking at my profile. It turns out that my chin was a bit recessive anyway, so this surgery just moved it into a proper position.

Warning: This next part is kind of graphic. Those with sensitive stomachs might want to stop reading here with the knowledge that everything turned out okay in the end.

I did have a complication 1 week after the surgery. The stitches over my right tonsil (or more accurately, the place where my tonsil had been) broke, and there was a lot of tension on the area. On February 14th, yes--Valentine's Day!-- the area became overly weakened and I started hemorrhaging blood. It was terrifying and very gross. I was typing at the computer when I felt something strange in my throat. I ran to the bathroom sink in time to spit out a mouthful of blood. With blood profusely pouring out of my mouth, I managed to gasp "Call the doctor!" as Kevin rounded the corner to see if I was okay. Kevin got a hold of the doctor's office, who advised us to go to the nearest emergency room, and brought me a chair as I was very close to passing out. We briefly discussed our options (Go to Stanford? No, too far. Go to Gilroy? Yes, closest hospital. Drive or call an ambulance?) and since the bleeding seemed to be slowing, we decided it would be quickest to just hop in the car and drive to the hospital instead of waiting around for an ambulance. We tossed the dog into the crate, I clutched a roll of paper towels and a plastic bag, and a very worried and shaken Kevin sped us to the hospital.

Here's where the story goes downhill. On the way to the hospital, the bleeding slowed and then stopped completely. At the time, it was an enormous relief and both of us were glad. Upon arriving at the emergency room, however, the gravity of our situation set in. See, if there's one thing that we've learned from our emergency visits, it's this: when you arrive at the emergency room, you want to be actively bleeding! Bring along a bag of pig's blood to toss over yourself as you go in, stick a knife in your head, whatever...just be actively bleeding when you arrive. (sidenote: we witnessed that being in active labor works too) Unfortunately, we were no longer actively bleeding, and thus in for a very long wait.

We waited and waited and waited. And when we were done with that, we waited some more. Finally we got into a room that was sectioned in half by a curtain partition. On the other half of our curtain, there was a 6 year old boy who had been bitten by a dog on his ear and required a few stitches (I believe the final count was 4 stitches for him). The doctor was a visiting intern/medical student/something who was not, shall we say, very good with children. The boy was understandably terrified, particularly about the prospect of getting a shot. The doctor, very unwisely in my opinion, lied to the boy, telling him there wouldn't be any shots. Well, of course there were because the ear had to be numbed before being sutured. Having just lied to the child, Dr. Dumb then whips out a syringe behind the boy's head and attempts to give the boy a shot in his ear. The mother spoke a concerned "What are you doing, now?" (having been lied to along with the boy), and at the same time, the boy realized something BAD was happening beyond his vision, and went ballistic. Honestly, I couldn't blame him.

Keep in mind that we saw none of this, and only heard it through the curtain. Anyway, Dr. Dumb proceeds to show the boy the syringe and admit that there might be one or two shots, but of course having completely lost his credibility with the child, the hysterical sobbing did not cease much. Finally the mother managed to calm the child down. Unfortunately the boy was now very tense and suspicious with a heightened sense of awareness, and continued to cry in varying tones and volumes (at one point we heard Dr. Dumb say, exasperated, "But I haven't even touched you yet!" at which the boy cried harder, knowing that the worst was yet to come). Needless to say, the whole ordeal left the child and his mother in tears and Kevin and I were very close to crying ourselves. After that was over, Kevin declared that should any emergency befall our future children, I should be prepared to take them into the emergency room myself.

[From Kevin: Shelby forgot the best part, which was that the boy wasn't just screaming and crying incoherently; anytime he'd sense that a needle might be getting near, he'd start repeatedly screaming "Help me, Lord Jesus! Help me, Lord Jesus God!" at a fever pitch. That's when I made her promise to be the one to take our future children to the emergency room.]

Finally, the doctor came to see me. Fortunately it wasn't Dr. Dumb of the stitches incident, but this doctor wasn't much wiser. He peered into my throat and looked very confused. "I can't find anything," he said. "Did you bite your tongue?" Did I bite my tongue?!?!?! Hello!!!!! Kevin's response was "Ah, no. There really was quite a bit of blood." Our doctor then left, puzzled, and later returned with the senior physician (whom I recognized from my appendix ordeal, though he didn't seem to recognize me). The senior physician also looked down my throat, and then instead of making himself look like an idiot by asking if I had bitten my tongue, admitted to me that as an emergency physician, he really had no expertise in ears, noses, and throats. What was worse is that the Gilroy hospital did not have an ENT on call, so there wasn't an expert he could call in to see me. He explained that post-surgical bleeding patients are almost always admitted to the hospital for observation, and that he could admit me here at Gilroy, but without an ENT, the best we could do if I started bleeding again would be to round up a general surgeon and let him have a go at me. Kevin very helpfully produced the name and phone number of Dr. Troell, my Stanford surgeon, and we all agreed to seek his advice.

We were then transferred from our bed to an ER holding area, where we learned Emergency Room Lesson #2: If you have a bed, don't give it up unless you are dead or are going home! Of course, not knowing that we should hang on to the bed at all costs, I was moved to a wheelchair and placed in a corner of the ER. It was getting crowded, so the bed space was going to other, more "critical" patients (see 'actively bleeding,' above). But at least I had a wheelchair. When it became clear that we were going to be there for a while, Kevin managed to round up a stool for himself. As the time passed, we got to watch the comings and goings of the ER. Okay, it wasn't quite like the TV show, but it was interesting nonetheless. Every once in a while the senior physician would return with the news that he couldn't get ahold of my doctor. It turned out, of course, that my doctor was on his way to a conference in Florida and was busy packing and whatnot. We waited, chatted with another woman in a wheelchair who'd been placed in our temporary holding area as well, and waited some more.

At this point, we learned Emergency Room Lesson #3: If you're not actively bleeding or in labor, come in handcuffed to a gurney accompanied by a police officer. Apparently the Gilroy police spend a great deal of time accompanying the drunken and disorderly adolescents of Gilroy to the hospital. Drunk Boy earned himself strapped arms and legs after attempting to walk off angrily, apparently oblivious to the fact that he was still partially attached to the backboard he'd come in on. His loud litany of swear words punctuated by ceaseless moaning earned him a room all by himself too. They even had to wheel out a man who looked at least 150 years old to give Drunk Boy a room. Once they shut the door though, it was worth it.

Finally we get ahold of Dr. Troell, who seemed slightly miffed that the Gilroy doctors had kept me there instead of sending me up to Stanford as any reasonable person would do. The Gilroy doctor, on the other hand, was slightly miffed that Dr. Troell wanted me transferred to Stanford without clearing this through Stanford first--that is, he could send me, but they wouldn't take me when I got there. After a few rounds (and several hours), we were presented with 3 options:

• Go home, against medical advice
• Go to Stanford via our own car (and risk bleeding again during the hour long trip up there)
• Go to Stanford via ambulance

Our Gilroy doctor informed us that it was hospital policy to transport patients between hospitals by ambulance, and that sounded just fine to us. Except that it would involve waiting for Stanford to send the ambulance down. Did I mention the hour long trip yet? So it would be at least another hour before the ambulance would even arrive.

So we waited and waited. Eventually we were offered another bed and immediately jumped on that opportunity. Dr. Troell called from the airport before his flight to Florida to make sure that all the arrangements were made (which I thought was very nice). At around 10 pm, the ambulance arrived, and I left for Stanford while an exhausted Kevin headed home to the hysterical dog and the bathroom that looked like a war zone. Having arrived at the emergency room at 2 pm, these 8 hours proved to be a record for us.

I slept through the ambulance ride and made it to Stanford around 11 pm where I was greeted by my favorite nurse from the week before. I slept well until about 4 am, when I woke up with a funny feeling in my throat. AAAAHHHHHH!!!!! Nurses came running, fetching items ("Go get an ice pack!" "We need a bigger basin!"), trying to peer down my throat with the flashlight, paging the surgeon on call posthaste. Within minutes Dr. Li arrived. He was the surgeon who had assisted Dr. Troell with my surgery, so he was very familiar with my case. He took a quick look down my throat (which was impossible because of the blood) and summed up the situation. The bleeding could be two things: broken blood vessels, or the artery. The broken blood vessels could be chemically cauterized, which he was preparing to do as he spoke. If it turned out to be the artery though, I would have to go back into surgery for a laser cauterization. He then proceeded to stick what looked like long black Q-tips but were in reality silver nitrate sticks down my throat, which caused a great deal of pain but fortunately stopped the bleeding.

To make a long story short (too late--ha ha) no further bleeding occurred. My blood count was very low, so I was given the option of getting a transfusion or taking iron supplements and limiting my activity. Since I didn't have any big plans for the next two weeks, I chose the latter. I ended up spending three additional days at Stanford just in case, and have to admit that after that ordeal I was very nervous about going home. It was good to get out of the hospital though, and of course since I'm writing this 4 months later, we all know that there were no further complications and everything turned out okay.

Upon his return from Florida, Dr. Troell explained that this type of complication was pretty rare, and in fact I was his first patient in the last 2 years to have this happen. To this day he says "I'm sorry you had to go through that!" every time he sees me. It's become a joke between Kevin and I whenever I have an appointment. "So, did he apologize about the bleeding again?" "Yep." All in all, I would definitely do this again, even with the complication. And I feel very lucky to have been at Stanford instead of at home or Gilroy when the bleeding started up again.

And that's the rest of the story :).