Bye Boobs – Part 2

Bye Boobs – Part 2

In the OR I closed my eyes as me, like I’ve always known myself to be. A blink later – actually, about 5 hours later – I opened my eyes to my new body, with enough attachments that I felt like an octopus trapped on land.

My chest was covered with an activated charcoal dressing over which a wound VAC (aka wound vacuum assisted closure dressing) was placed. There is one wound VAC dressing on each breast, with a tube from the center of the dressing which extends out to a portable vacuum unit which creates negative pressure under the dressing allowing the dressing to kind of suction onto my skin. Wound VACs promote wound healing by:

  1. Draining excess fluid from the wound
  2. Reducing swelling and inflammation
  3. Reducing bacteria in the wound
  4. Keeping the wound moist and warm
  5. Drawing the edges of the wound together
  6. Increasing blood flow to the wound https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/vacuumassisted-closure-of-a-wound

The wound vac isn’t uncomfortable, rather, I feel it feels supportive, like it’s holding everything together. Since they cover the incisions, I don’t feel any incision sensitivity or irritation from clothing rubbing against incisions (something I had after my oncoplastic reduction). And it’s helping my wounds heal. So, I can’t say it’s really bothering me. 

The only issue might be how I’ve accepted it as a part of my body… The other night, as I was getting out of my bed to use the restroom, I looked over to my portable vacuum unit and said out loud, “let’s go!” Then quickly checked myself – the vacuum unit is not your daughters, it is not your dogs, and even though it hums and beeps, it is not alive and it is not part of you. It’s not going to do anything on it’s own. C’mon Kavita, pick it up and take it with you.

Just below the edges of the wound VAC, several inches inferior to my armpits, I had Jackson-Pratt drains (aka JP drains) – 2 on each side. The tubing of these drains extend into my chest and snake out to connect to a small bulb (with a one way valve allowing fluid into the bulb but not backward into the tubing). Negative pressure is created in the bulb by squeezing the bulb prior to sealing it, each time the fluid is emptied. The purpose of the drains is to remove the serous fluid and blood that naturally accumulates in the chest wall tissue after surgical manipulation and to prevent formation of hematomas and seromas which can impair healing and lead to infections. Each day the drains need to be stripped from where they insert in my skin, down to the bulb and then the fluid in the bulb is squeezed out and discarded.

Oh, and I had a foley catheter in! Fortunately, placed after I was already unconscious in the OR and removed early post-op.

My biggest fear going into the procedure was post-operative pain. At the recommendation of my surgeon and after discussion with my anesthesiologists, I elected to have paravertebral nerve blocks placed. It is similar to an epidural but rather than being placed midline or anywhere near the spinal cord, a very tiny tube is placed on either side of the vertebrae where the nerves that provide the sensation to my chest exit from the spine. They were placed at T4 or at level of the 4th thoracic vertebrae for my mastectomy.

The placement involved assuming the position like you would for an epidural and was easier than having an epidural placed simply because I wasn’t pregnant or contracting! There were two small pricks in my back, a brief twinge from local anesthesia and then all I felt was some pressure and movement as the blocks were placed.

These small tubes ran from my back to two fist sized balloons of medicine (ropivacaine) that provided a continuous infusion of medicine for about 6 days. The balloon balls had some weight in the beginning when they were full of liquid. I placed them in internal pockets on my post-mastectomy zip up hoodie and the weight pulled them down together in front of my groin, like big, saggy, … you get the idea. Minor inconvenience for such an immense service.

Let me tell you, they made a HUGE difference. Compared to my oncoplastic reduction 2 months ago, with these nerve blocks, I woke up after surgery with less pain, didn’t use any PRNs (additional “as needed” pain meds) while in the hospital, and didn’t require any narcotic pain medications post-operatively. After my oncoplastic reduction, I received dilaudid immediately based on my pain  level and took ibuprofen and oxycodone for 1 week after the surgery. So the paravertebral nerve blocks were a big win for me. 

Thank you GW Department of Anesthesiology and to my acute pain management team for their attentive and comprehensive care. This process has given me tremendous insight into management of pain as a patient. I think we may struggle to understand our patient’s pain as physicians and based on my experience as an ER doctor, pain management can be a point of frustration for both patient and physician when not executed well. This topic is worthy of it’s own post.

With pain under control, my biggest challenge at home was physically managing my tribe of tubes. My Mom and my husband took turns as my drain managers. My Mom is the OG doctor mom but had no prior experience with JP drains. They both learned how to carefully strip the fluids through the tube into the bulb, aseptically empty them into a cup, measure, record and track the amounts from each tube and then dispose of the bloody fluids. I was dependent on them for my morning coffee, putting on clothes and for less glamorous things like bathing. Well, sponge baths really, like you’d bathe a small child. 

I have never felt so dependent on someone else. The transition from being self-reliant and self-sufficient and a carer of others, professionally and personally, has been humbling. Even now I struggle with defining my own limits. But my body signals loud and clear when I’m pushing it too far and I resort to asking for help. 

In the emergency department, I am comfortable knowing my limitations and whether it’s more hands, or a consultant, or security, I readily recruit help for the sake of my patient. Somehow this is much harder to apply to myself. Shame and a slight sense of failure accompany realizing when I can’t do something, especially, when it’s something I had so recently been able to do. I mean, who wants to ask for help cleaning themselves? Recognizing that I can’t perform my basic activities of daily living like, cooking, using the restroom independently, or (hardest of all) caring for my two kids is nothing short of depressing.

Through the last few months I have been forced to reach for help. And guess what? I didn’t explode and I never received any emails stating, “Kavita Jackson is officially a failure.” I was no less of a person. I was no less of me. In fact, I felt relieved. My shoulders were lightened by the increasing burden of myself. Acknowledging my vulnerabilities actually strengthened me, for the sake of me.

The next several weeks of recovery will include rediscovering my new chest, nourishing myself and working on rebuilding my physical strength so I can return to the emergency department ready to hit the ground running. I am energized and proud to be on the other side of all of this.

Kavita Jackson, MD

Bye Boobs – Part 1

Bye Boobs – Part 1

5 days ago, my breasts were surgically removed. This is known as a double or bilateral mastectomy. I reached remission about 8 weeks ago after undergoing an oncoplastic reduction. My surgery included removal of the tumor (aka partial mastectomy or lumpectomy), sentinel lymph node dissection and a bilateral breast reduction. Oh, I also had an ovarian dermoid cyst, ovary, and fallopian tube removed as well as my port. That’s a mouth full, let’s break it down.

The purpose of oncoplastic reduction is to remove the tumor bed and evaluate for any remaining signs of cancer and requires several steps prior to the actual procedure. On the morning of my surgery a radiologist identified my tumor using ultrasound and injected a radioactive seed into it to help my breast surgeon visualize it accurately later in the OR. Then another radiologist injected a radioactive tracer at the edge of my areola – albeit a brief burning and stabbing sensation, this injection was the most painful one I’ve had. This tracer, in addition to a blue dye injected into my breast in the OR and a special imaging technique called lymphoscintigraphy allowed my breast surgeon to identify my sentinel lymph node.

 Image ID Copyright: ellepigrafica / Shutterstock

The sentinel lymph node(s) is the first lymph node that the affected breast drains to. It is removed to be evaluated for cancerous cells. Theory being that if the cancer were to spread from the breast, it would go through this particular lymph node first. So, if this lymph node shows cancer cells then it indicates that the cancer has spread outside the breast. This has largely replaced the previous practice of removing all the lymph nodes that the affected breast drains to, which was a more aggressive technique that is associated with side effects like lymphedema (swelling in your arm or leg). 

My breast surgeon also removed my port, which I was arguably most excited about. It wasn’t something I ever wanted or identified as part of my body. It made me feel sick before I actually was ill from chemo. And as long as it remained in me, I had a lingering fear that somehow, someway chemo would flow through it again. It’s removal finalized in my mind that my chemotherapy really was done.

Next up was my plastic surgeon who reduced my left breast to match my new right breast. Then my gynecologic oncologist laparoscopically removed my ovarian dermoid cyst which was incidentally found during my initial work up of breast cancer. The large size (6cm) made it high risk for an emergent condition called ovarian torsion, so it was recommended to be removed. Unfortunately, when my surgeon opened me up, she noted that the cyst indistinguishably engulfed my ovary and thus my ovary and fallopian tube were also removed. Of course, this was a possibility that she had discussed with me at length prior to surgery to prepare me. It is what it is.

It is unbelievable the immense collaboration that was required between 2 radiologists and 3 separate teams of surgeons to make this possible for me all on one day. Not only that, my radiologists, oncologist, breast surgeon, plastic surgeon, gynecologist oncologist, and anesthesiologists – all women! Surrounded with love, compassion and encouragement, I headed into surgery with minimal hesitation.

The entire affair was led by my breast surgeon, the amazing Dr. Christine Teal – Chief of Breast Surgery at George Washington University and quite the inspiration herself. In 2010 she chose to undergo a prophylactic bilateral mastectomy after experiencing her mother battle breast cancer twice. She made this decision without being diagnosed with cancer herself or being tested for the BRCA gene (BReast CAncer gene). This was also before Angelina Jolie’s prophylactic bilateral mastectomy in 2013. The media coverage surrounding Jolie’s move, based on being BRCA positive, increased the public’s awareness of this option and made it seem less radical. But Dr. Teal was a trailblazer before Jolie. With true humility and an unbiased approach to her patients, Dr. Teal never mentioned her story to me. I found out by my Dad who forwarded me her moving and insightful feature in The Washingtonian -> HERE <-.

1 week after my first surgery the results of my surgical pathology evaluation of the tumor bed and sentinel lymph node were negative for any signs of cancer. Hence, I reached remission. 

Remission could have been the end of my breast cancer journey. However, my biggest concern going forward was the risk of recurrence. I wanted to ensure to the best of my ability that I would never ever have to go through this again. Based on the characteristics of my breast cancer I was quoted a 1% risk of recurrence per year which accumulates each year! Meaning in 5 years, 5% risk of recurrence; in 20 years, 20% risk of recurrence.

HELL NO!!!!!!!! Not acceptable to me. I may have felt differently if I wasn’t in my 30’s. Without hesitation I pushed on to have both my breasts removed. Since there is no such thing as “never” in medicine, even with a double mastectomy the risk of recurrences is approximately 3% over the rest of my lifetime. This is the lowest possible risk I can obtain through my control. So, bye boobs.

Kavita Jackson, MD