Sunday, March 10, 2013

My Own General Contractor -- or -- The Exclamation Point (Part 15)

Extreme discomfort.  Not really pain, but I am not well.  I can't see.  My eyes are swollen shut, and I sense that my face is heavily bandaged.  My back aches.  Some device seems to be compressing my legs at regular intervals, perhaps to keep the blood circulating?  My throat is as dry as sand, but I moan a rasping question, "What time is it?"  Someone answers that it's 11pm.  I remember being wheeled to the operating room at noon.  The same voice tells me that I will be kept in the intensive care unit (ICU) for the night.  I moan for water and am given a small drink through a straw.  I then moaned one phrase over and over again:  "OD.  Tell OD I'm here."  No one replied.  Perhaps the ICU staff thought I was delirious? 

This is my report card for the Phuket International Aesthetic Center (PIAC), the Phuket International Hospital (PIH), their surgeons, and their staff.  The title of this post gives the hint of what the grade will be.  At PIAC, you are your own general contractor.  During my long night in the ICU after 9-10 hours of surgery made up of 2nd stage gender confirmation surgery (GCS) followed by 1st phase facial feminization surgery (FFS), I had ample time to ponder whether I was qualified to be the general contractor behind my own surgical fate.

What do I mean when I say that at PIAC you are your own general contractor?  Quite simply, you, the patient, are the one in charge of your treatment.  You are in the driver's seat, the one who makes the decisions of what surgical procedures to undergo, the one who decides how much discomfort can be endured.   It is a very American trait to want to be in control of the buying process in any major purchase, but in the case of major surgery, should I be the one in charge, the general contractor who makes the major decisions?  I'm not sure.

I think back to a year ago when I first corresponded with PIAC.  One aspect of the correspondence that immediately appealed to me was that Dr. Sanguan Kunaporn, the surgeon for gender confirmation surgery (GCS), corresponded with me directly before turning me over to his administrative office.  I noted early on that I was considering some degree of facial feminization surgery (FFS) in parallel with GCS, to which Dr. Kunaporn replied, "Yes, if the FFS is not really very extensive and you have approx. 1 month time in Phuket, I have no objection."  He then put me in touch with the Dr. Rushapol Sdawat, the craniofacial surgeon who performs FFS at PIAC.  In the following weeks based on photos that I provided, we decided on several facial procedures that would be beneficial.  After that, it was a matter of waiting.

A driver and one of PIAC's international coordinators met us at the airport in Phuket on January 20 and took us to our hotel, the Aspasia Resort in Kata Beach.  Two days later we reported to PIH.  OD was admitted that day, and I was admitted the next.  The admission procedures were straightforward and efficient.  After admission, we were taken to the PIAC office, where one of the English-language coordinators welcomed us before sending us on our way with a technician who took us first for an X-ray and then to our room.  Up to that point, our PIAC experience rated an A grade.

Our first qualms started when we were in our room.  The nurses and assistants, every one of whom we came to love, spoke only the most limited English.  Even ordering OD's first meal was not easy.  With time we came to joke over thrice daily ordeal of ordering meals.  "Hot green tea" and "guava juice," both of them listed in the menu, caused consternation, as though they were ordering exotic beverages from Mars.  With time we would point at OD and say over and over again "hot green tea."  Then we would point at me and say "guava juice with ice."  These became mantras.  By the time we left the hospital, we had concluded that OD should begin teaching the staff English, as her very limited English was generally better than that of much of the nursing and support staff.

If we had trouble ordering meals, just try to imagine the difficulty we had with medical issues.  I will never forget the night when I had a splitting headache that would not let me sleep.  I pressed the call button more than once, and the assistant on duty came immediately each time but seemed unable to understand that I wanted something for a headache.  In exasperation, I finally got up and walked to the nursing station.  There was an empty chair.  I sat in it, put my head on the desk, pointed at my head, and repeated again and again, "Headache."  Finally one of the senior nurses heard and understood.  I got my Tylenol.  

Thus my overall grade for the nursing and support staff is B-.  That's made up of a C- for English ability and an A for caring once they could be made to understand.

Dr. Sanguan Kunaporn
What about the surgeons?  Both Drs. Sanguan and Rushapol get an A- or A in my book for technical expertise.  In transgender circles, Dr. Sanguan is the better known of the two.  He is professional and caring, no doubt about it, but he is also busy.  We first met him in person on the night of OD's admission, and we did not see him again until the next night, the eve of OD's first-stage GCS.  Our direct contact with him was at all times limited to what was necessary:  the operating room, brief post-op checkups, dilation instruction, and suture removal.  That said, he was always ready to answer our questions.  We just had to remember to have them ready to ask during those brief windows of direct contact.  He gets an A for bedside manner and a B for availability.

With Dr. Rushapol Sdawat, Two Weeks after FFS
I knew less about Dr. Rushapol before going to Phuket, but by the time we left, I felt I knew him better than Dr. Sanguan.  First there were the pre-surgery photo sessions and discussions of what procedures to do, what procedures to leave out.  I've already noted in my previous post that Dr. Rushapol fed me personally, spoonful by spoonful, in the ICU on the morning after the first phase of my facial surgery.  I saw more of him in the days and weeks following surgery than I did Dr. Sanguan.  I will never forget his caring, gentle, and soothing voice.  He gets and A for technique, an A+ for bedside manner, and an A- for availability.

Although I did not know it before we arrived in Phuket, I was indeed my own general contractor at PIAC.  I had naively expected that Drs. Sanguan and Rushapol had discussed between themselves the extent of my surgeries and what was reasonable.  In retrospect, I imagine that if such a conversation took place, it was of short duration.  There was no one at PIAC to serve the function of patient advocate.  I say that even though I came to love the young women who work there as international coordinators.  It's not the same thing.  There is no one to sit with the patient and review the overall treatment plan, expected results, and recovery timeline.

I had ample time while bandaged and with limited sight to recall  that what I was encountering in Thailand was not necessarily that different from what I would have encountered in the US.  I thought back to an earlier time in my life when my sister-in-law landed in the ICU at a hospital in Maryland.  She was there for months.  It did not take many weeks for us to realize that there was no one "in charge."  Many different specialists came and went, but no one seemed to have the high ground with the overall view of my sister-in-law's treatment.  My ex-spouse rose to the challenge.  She became the greatest and best patient advocate I have ever known, cracking the whip over nurses and doctors alike.  She became an expert on the hospital structure and organization and learned how to work through it to get the best possible treatment for her sister.  She became the general contractor who organized the work of doctors and staff.  THAT is what is missing at PIAC.

As we came to grips with this fact, OD and I did the best we could to be advocates for each other.  I would not recommend that anyone go by themselves for GCS or FFS anywhere in the world.  OD and I had each other, commiserating in discomfort, keeping up each other's spirits, and laughing when we could.

Should I as general contractor have ordered such extensive surgery in such a short period of time?  In retrospect, I would say the answer is NO.  Three major surgeries, twenty-four hours of general anesthesia, and days of morphine are a heavy load for the human body to bear.  If I had known six months ago what I know today, the rational side of my brain might well have decided that GCS and FFS should be done separately with perhaps a year in-between.

When we were released from PIH, OD and I returned to the Aspasia Resort.  My face was black and blue, still with bandages in many places.  I attracted stares from everyone and quickly came just to nod my head yes when people would ask if I had been in a motorcycle accident.  I had lost all feeling and motion in my left foot during the long 2nd stage GCS and 1st phase FFS surgery, a classic case of drop foot likely caused by a pinched nerve from being in a gynecological position for so long.  

Working Out at the Aspasia
Despite this, within days I was doing light workouts on the elliptical machine in the resort's workout room.  In the evenings I would walk down to Kata Beach and walk from one end to the other and back.  As general contractor, I had decided that my recovery should be as active as my condition and energy level would allow.  I might have been capable of only a third of the physical activity I had been used to prior to surgery, but a third is not zero.  With each day I could feel myself get stronger.  The memories of my night in the ICU began to fade.

One Day Before Returning to Bucharest
Now back in Bucharest some six weeks after my 1st stage GCS, I am well on the path to full recovery.  All the scars and bruises on my face have disappeared, and the swellings are diminishing.  Dilation goes well three times per day, and I can now sit in most any chair without using a donut cushion.  In fact, I briefly road my bicycle on rollers today for the first time since before surgery.  Perhaps in another 1-2 months I will be able to ride it for longer intervals and return to the road?

So from the perspective of today, I am glad that I said YES to all the surgeries six months ago.  Even if this general contractor should have paused before ordering so much surgery, today she is glad she did it all.  It is over and done, and I can move on with my life.

It is premature for me to give a final grade to PIAC and my GCS/FFS experience, but as of today, I would say the overall grade is a healthy B+.  (Kata Beach gets an A+ as a wonderful location for initial recovery.)  To anyone else thinking of PIAC for GCS and FFS, I would just say do your research and evaluate your own physical condition and what you can endure in a short period.  If you are comfortable being your own general contractor, PIAC could be the right choice for you.

Final Sunset from Kata Beach

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Follow these links for more of The Exclamation Point:
Previous entry -- My Million Baht Body
Following entry -- Home Sweet Home in Romania


  1. Thank you for this and your other posts about PIAC and Dr Rushapol. I have found them balanced, informative, and helpful in considering them for a breast lift and tummy tuck. You look lovely after your surgeries. All the best to you.

    1. I am gratified to know that my jottings were of use. May your own path be smooth and lead on only to better things!