Upcoming Surgery

I now have 3 blogs that are almost finished, but I'm starting another new one. Why? Because this topic is overwhelming me, so I want to write about it now. 

I need another surgery for endometriosis. I am scheduled for an endo-specific MRI in 3 weeks, and then I'll schedule the surgery after that. My last surgery was in 2018. Now in 2026 my surgery will be more advanced. I learned a few things to share here:

1. The last time I had surgery, I had an ultrasound first. That ultrasound did show possible adenomyosis, but my doctor never talked to me about it. It's likely she wasn't trained in it. My new doctor told me about it after reading the notes. I also learned that my ovary was tied to my fallopian tube with endo adhesive, and it's possible that they are stuck together again. So I had another ultrasound a few weeks ago, and it still shows probable adenomyosis. I was becoming suspicious of adenomyosis on my own because 1-3 times per year I do tend to bleed heavily for more than a week during ovulation. Last month I bleed through 2 periods and two ovulations before it finally stopped. 

My ultrasound also showed free fluid in a place where I had endo removed before, so it's probably endo. It also showed that my right ovary is 3x larger than my left, and the cyst that was previously removed must have grown back. My last surgeon warned me that she couldn't remove all of the endo on my ovary without removing the ovary, and when endo isn't fully removed, it grows back. 

2. My doctor suggested this new type of MRI that's specific for finding endometriosis. It can't see it all, but it should help locate some of it before she does surgery. She said this helps her prepare, and possibly schedule a second doctor to help if the MRI shows it on my colon. Regular MRIs cannot see endometriosis, but this new version might. It might also help diagnose what type of adenomyosis I have, which could help me choose treatment plans. 

So what is adenomyosis? Basically, it's like endometriosis (it's not identical, it's more of a cousin), but growing inside of the uterus instead of outside of it. It cannot be seen during surgery. Modern imaging might be able to detect it. Apparently the only official way to diagnose it is by surgically removing the uterus and opening it up to see if it's in there. Adeno causes extremely heavy bleeding and increased pain with contractions (like during the period). It's also a known cause of chronic fatigue, like endo is.

3. After the MRI I'll have surgery, but I hope to delay it if possible. I'm going to attend a wedding and work my job for a couple of weeks because it's a busy time of year at work. Then I'll do the surgery, and I'm expecting I'll need at least 3 weeks of recovery time, maybe more. If they find something very urgent that needs to be surgically handled, then I suppose I can't wait. My pain really has increased too much and I know something is wrong, so we'll see what they find. But I have to wait weeks for the MRI anyway. 

My new doctor is much more advanced in endo surgery than my last (I'm not saying my last doctor was bad - she did as good of a job as possible in that situation), and she told me that if I choose to travel to one of the best surgeons that she will help refer me and get me in. I'm torn on this one, because she may be capable of doing a really good job for me and she's right here in town. I really don't want to have to travel. She was trained at Mayo and is using the latest techniques, and she gets all the continuing education available. She isn't an endo-specific surgeon, but she is much more focused on endo and more highly trained than the average gynecologist. The surgeon we choose is extremely important, because if the surgeon isn't capable of removing ALL of the endo, the endo will come back and we'll need more surgeries. That's what happened to me, and it's normal. The best surgeons reduce the risk of needing multiple surgeries. 

This doctor, if I choose her (and I probably will, depending on the MRI results,) will do a different surgical method than my previous surgery called a Peritonectomy, or Peritoneal Stripping. I understand that the recovery period is longer.  In this version, she will remove the top layer of my internal skin. That will help remove the roots of the endo that might be invisible to our eyes and cameras. The tissue will regenerate, but I understand it's going to be a slow and painful process. 

I can't find a good website to explain the peritonectomy surgery, just various studies about it which are not in lay-people terms. I did find this video that briefly explains why it should be done:

4. Treating the adenomyosis? This is what I'm really unsure about, especially since I've been trying to treat it naturally for so many years, and because of where I live I've lost access to treatments that were helping (like acupuncture!) I have 2 medical options: remove the uterus, or insert a progestin-only IUD like Mirena. I'm not willing to remove my uterus unless it's trying to kill me, and it's not that bad right now. I'm really uncomfortable with the idea of the IUD, but I understand it. I already use bioidentical progesterone, but it can't make it into the uterus where it's needed to treat the adenomyosis. An IUD is used because it can release Progestin inside the uterus where it can do its job. Natural progesterone can't be used because the half-life is too short. I would need to replace the IUD very frequently, which is unsustainable and very painful. Synthetic Progestin has a much longer half-life, so it makes the IUD sustainable. 

But am I willing to use Progestin? I really don't want to because I'm too familiar with the side effects, and I tend to be extra sensitive. I don't know for sure, but I think I prefer the heavy bleeding and pain over the change of personality from the Progestin. I don't like the increased risk of ovarian cysts from it too. I don't like how it changes our sense of smell and cause weight gain too. I'm not a fan of the risks. 

I have read that there are newer treatments for specific types of adeno, such as a new type of ultrasound machine that can help shed it off. I don't know what type mine is, and I don't know if anyone locally offers that treatment. I need the MRI results first. 

What can I do naturally? Well, maybe I need to stop eating goat cheese and be totally dairy-free again. Maybe I need to increase my fiber. Maybe I need to go totally carnivore. Maybe I need to reduce my sugar intake to zero again. Maybe I need glutathione IVs again. Maybe I need to drink more red raspberry leaf and hibiscus, except that my blood pressure already runs low. Maybe I need to do daily castor oil packs. Maybe I need to go back on my previous herbal blend pills. Maybe I need to travel for an acupuncturist who knows what they're doing. The thing is, I've done all this since 2013. I was able to improve about 50% at best (which is really good!) If I've slipped into some bad habits and that's why my symptoms are increasing, then I can fix that. But the fact is, I was never able to fully manage naturally. And I was working with excellent natural doctors. 

So, I'm undecided on what to do about the adenomyosis. My head is too tired, and I think I'd prefer to get the MRI results first anyway. 

There's more and more research about endo coming out - such as the estrogen and histamine link, the mast cell link, the new saliva biomarker, and so on. Maybe adeno will be similar and we'll find ways to help manage it soon. 

Alexia Evellyn - Hold On

Sometimes we just need power ballads to help us find our strength to continue being women,,, because this isn't easy. I'm numb to the emotions of the pain after all these years, but I still have to feel the pain. I just surrender to my period every month and don't try to live my life until the worst passes. I'm a veteran at this, but I'm so tired of it. I'm scheduling my whole life around my periods, and so I don't like to plan my future because I never know if I can really be available for it. 

I dreamed last night that I was locked in a prison cell with no way to manage my period, so I laid on the floor and let it all bleed out into a giant pond in my cell. It actually felt like a pretty good analogy for my life. And so, am I crazy to want to keep my uterus? What if I explored the idea of letting them remove it so I can be free? And then I'll never be able to have children... that's not the life I want. All I ever wanted in this life was a loving husband and children. I'm not ready to abandon that dream. Can you understand the distress this puts me under? It's enough to break a woman. And I think I did break a few times already. And yet, I don't stop dreaming of the life I wish I was living. A simple life full of love and family. Maybe, just maybe, after this surgery I can make it reality. 

Endometriosis Awareness Month: A Glimpse Into My Reality with Endo

It's endometriosis awareness month. 

First, here is an awesome Facebook post with some info about what Endo is and what it is not:

I'd like to write about my current cycle in honor of raising awareness. 

A little personal history, for context.

I've had extreme periods since I was 17. When I started to use menstrual cups, I counted how much I bled on the first day of period over years. I normally filled my size 2 Diva Cup 3-7 times full in the first day of my period. The average person fills their cup 1-2 times full through their entire period. Along with this heavy bleeding was excruciating pain. Full body pain. I could move a toe and feel it cramp up my leg and trigger pelvic pain that felt like someone stabbing me with a knife repeatedly. I also had relentless diarrhea, which was super painful. I could sit on the toilet and feel my heart rate skyrocket to the point where I was seeing stars, seeing my vision slowly go black, and I would gasp for air. All while my body purged itself beyond my control. Yes, I've fainted from all this. I took up to 12 ibuprofen on the first day of my period for years, and it didn't work well. I kept taking more hoping for any pain relief at all. I was like this for years and years. Finally, a doctor told me my liver was in poor condition, and I admitted taking all these painkillers (and a daily Allegra D) to him - he warned me to stop because that was causing a lot of damage to my liver. So I was left with no real option for managing my allergies and pain in the conventional way. (I always refused birth control as an option for religious reasons, but also because I read all the side effects and didn't want them. Doctors did drop me because I refused birth control.) 

In 2013 I started to work with a Naturopathic Doctor in New Hampshire. We did a lot of work to improve my health. By following his advice, over a few years my periods slowly became about 50% less intense. My bleeding reduced down to 1-3 full Diva cups on the first day (still heavy, but manageable.) My pain was still intense, but he made a tincture for me that actually worked. It blocked estrogen receptors, which did reduce my pain a ton, but it also knocks me out. So when I take it, I sleep for hours through the worst of my symptoms. He put me on natural progesterone and hormone-balancing herbs, which made a big difference over time too. He changed my diet, which made a big difference. My PMDD was not as long or severe, my cycles were more regular, I didn't bleed as heavily, I was more stable during my periods with less fainting issues, and my level of fatigue wasn't as strong anymore. But I stopped getting better. Everything improved about 50%, which was miraculous to me, but I stopped improving more. 

In 2018 I was first diagnosed with POTS, and the next week I had a $14,000 laparoscopic surgery to look for Endometriosis. My surgeon was a local gynecologist doing the Davinci Robotic surgery. She was sure she wouldn't find endo - in fact, she was doing the surgery just to help me stop feeling convinced that I had it. She told me it would be a 30-minute surgery. She was wrong. It was 3.5 hours long, and she did find endo. She took a biopsy and confirmed it in the report, but refused to give me a "diagnosis" in my chart. Why? I don't understand that part, seriously. So when doctors see my medical records they only see the surgery, but not the result. Anyway, she removed endo from my Pouch of Douglas / Cul-De-Sac, which was probably where the majority of my pain was coming from. She also found it on my uterus and ovary. She was unable to fully remove it from my ovary without removing the whole ovary. The problem with endo is that if you don't have it fully removed, it grows right back. She also found that my uterus was tilted backwards. In the year after the surgery, my periods were the lightest they had been in my life. My pain was a little better too. But the results didn't last longer than a year. 

After my surgery, I was still bloated from all the air they pumped into me and my scars were bruising. 

In the last few years, my periods have been slowly getting worse and worse again. My PMS has been turning back into PMDD again. My cycles are less regular. What has changed? Well, a lot of stress in my life. I've stopped using the herbs as regularly. My diet has loosened up a little. And I think, most importantly, I've been unable to have regular acupuncture treatments in the past 2.5 years. Acupuncture made a huge difference for me.

I've always had to call in sick on the first day of my period. I never improved enough to be able to work on the first day of my period. I had to miss very important events in my life because of it. And despite all the medical care I've been though, all the extremely strict diet and lifestyle changes I stuck to for years and years now, and all the praying and therapy I've tried, nothing helped enough to give me a "normal" first day of my period. It always made me so sick that was bedridden with major pain, fatigue, and vertigo for the day. 


And now, for the present.

So let me talk about my current cycle, to give a glimpse into the turmoil I live with every month. I use the Clue app on my phone, and I pair with my Oura Ring. I'm not good at tracking all my symptoms, but I am very good at recording the first day of my period. So let's look at Clue for this month:

Each dot represents a tracked symptom per day. The red phase was my last period, and I only tracked for 3 days of it before I forgot. I bed 5 days, I think. The days with 2 dots are because of information my Oura Ring automatically sends to Clue: sleep and body temperature. Then the blue phase, which is ovulation, you can see extra dots. That's because I bleed dark purple thicky sticky blood for 3 days during ovulation. Then, when the 3 dots appear again, is when I started to record my PMS symptoms. I had symptoms for a few days before I started to record. I had acne, bloating, mood changes, scalp tenderness/ sensitivity, and fatigue issues, but they were not bothering me enough to think to record it. So I've had about 10 days of PMS symptoms. What does that mean for me? It means gaining a pants size in bloat, relentless hunger (even eating high protein with some extra carbs), very sensitive mood that causes me to feel everything too deeply, moments of unprovoked anger, days of irritability, feeling super anti-social, withdrawn into my head and difficult time being in reality, random cystic acne around my mouth and on my chest, ringing in my ears, deep fatigue that caffeine can't cure, nights of insomnia and then nights when I sleep 13 hours, very achy deep throbbing pain down my legs, vertigo and dizziness that makes me really unbalanced, sharp throbbing cramping all over my pelvis, feeling a bowling ball growing in weight in my pelvis, unpredictable bowel movements, throbbing aching teeth, swollen tender breasts that hurt to touch, sharp nerve pain in my breasts, inability to completely empty my bladder, and I'm sure there are symptoms I'm forgetting. 

 My period is late. "Late." I've had years with my average cycle lasting 30 days, and years when it was 35 days on average. I've just been in a 30 day average cycle this year, so now this looks late. 

The problem with me being late is that I've had many days of symptoms that marked what should be the beginning of my bleeding: major cramping, vertigo, and fatigue followed by an improved mood. All the symptoms that tell me it's time to lay in bed with my heating pad and stop doing anything else. Except that my bleeding didn't start. I've been in this state for about 5 days now, feeling on the verge of starting my bleeding. I had two shifts at work that were difficult for me to endure, but I didn't get bad enough to have to go home sick. I was mainly concerned about fainting, so I drank lots and lots of salt and took licorice root pills to keep my blood pressure high enough. 

Since I can't read my symptoms reliably, thankfully my Oura Ring gives me a clue that I can almost rely on:

(I recorded my period start day one day earlier last month, so the apps don't agree. That's because I started bleeding a tiny bit the day before, but without all the symptoms of my first cycle day. So I recorded a different day in each app to help me predict my next period.)

Ok, look at the body temp graph. The line is my baseline average body temp. Each day marks if I was higher or lower than my average. I tend to increase by a half degree to a full degree in the last 5 or 6 days of my PMS, and when I see my body temp drop below average, I'm usually ready to start bleeding. So you can see why this month is confusing: 3 days ago my temp dropped, but not below average. Yesterday it did drop below average, and I had all the symptoms that said my bleeding should start (including my breast pain going away.) But I only bled a tiny little drop all day. Ok, so today my temp was below average again. I checked my Diva cup this morning and it had a small stream of very dark black blood on the edge. I haven't bled more since then. 

I called in sick to work today. I am only writing this blog because I drank enough green tea to help warm me up, and I hoped the caffeine would encourage bleeding. The reality is that I'm sitting very still at my computer to type this. I'm taking lot of breaks to breathe and rest. I'm getting really dizzy at moments. I'm getting immense pain for brief moments. There's no way I can stand up for 5 hours to do my job like this. And I won't improve until I bleed. I am in limbo. I'm unable to function until I bleed. 

This is a glimpse into my reality with endometriosis. When I say it dominates my life, you can see why. I get maybe 1-2 good weeks per month where it doesn't limit me or control me. 

Florence and the Machine - You Can Have It All

This album was about her ectopic pregnancy and miscarriage that nearly killed her. She wrote many songs about the grief and the reaction of her fans. It's an album that will make you cry. This song, although about miscarriage, reminds me a lot of my experience with endometriosis. "Am I a woman now?" Is this what it means to be a woman? The loss of a child/ inability to have a child. Being controlled by our bodies. How to exist in the circumstances of our bodies?

Permanent Toe Nail Removal Surgery

Ha - I discovered this unfinished post as a draft. I'll publish it unfinished, nearly a year after the event. I should write an update on this situation, as my toe has not healed yet... 

The post:



Ooooookkkkkkkkk..... this is not a pleasant one. Permanent toenail removal. 

I'm NOT going to share photos of the wound. Unlike other bloggers... I didn't want to see their photos.

It would make you squeamish. I want to share my story to be helpful, and I know that gross photos will scare people away. I am going to share a few photos of bandages, shoes, and how my toenail used to be. These shouldn't be too much for anyone. 

PART 1: The Story

I had my left big toenails (yes plural) removed on October 18th. The damage began in 2018. The nail broke off the cuticle, a new nail grew in under it and pushed the original dead nail up. Then that new nail would break off and the cycle would repeat. I had 3 nails on my toe ever since, until this surgery. The nails were curling more and more as the years went on, and the pinching feeling was becoming unbearable at times. I didn't have a choice. It had to be done. 

Why did this happen? Well a Pulmonologist and Neurologist both thought that it was a side effect from taking Metaprolol to manage my tachycardia from POTS. Metaprolol did help lower my tachycardia, but it worsened my already poor circulation. My feet are normally icy and purple, but Metaprolol amplified the problem. I was going numb from cold, and my fatigue intensified too much. I had to stop taking it. These doctors said I probably cut off oxygen to my toes and I'm very lucky I only damaged the big toenail. I have had streaks on my other nails ever since, but I didn't lose them. 

My surgery was a horrible experience. Be warned, this story is something of a nightmare!

It wasn't exactly planned - my appointment got moved up a few weeks early, and I only wanted him to trim the sides down to reduce the pinching. I thought I could hold off on the surgery for another year, at least. Nope, he took a look and said I can't wait. So I had to get mentally prepared VERY quickly. I agreed to it, I knew it was coming eventually and already accepted the fate of my toe, but I didn't know it was going to be right then and there. 

The podiatrist has good bedside manner and has been good with me since I started working with him in 2018. I thought he was a good doctor. The trouble is that he works as quickly as possible, and he leaves the room quickly every time he isn't needed to do something for me immediately. He injected the numbing serum, I waited 10 minutes, then he came in and immediately started to put the tool under my nail. I could feel it! He didn't test my toe before starting the operation. He injected more numbing serum in a few spots closer to the nail until I was numb. Then he asked me to explain what POTS was. I looked away while talking, and in what was probably less than 2 minutes he said he was done. The top two nails came off very easily, almost without effort from him. That could have been a problem for me if I hadn't gone in for the surgery. And then he was gone and I never saw him again. 

His nurse is incredibly kind and friendly, gave me the attention I needed to pull myself together, and I loved her, but... and I don't know how much of this is her or the fault of the hospital being stingy...

She sprayed the wound with cold alcohol, then put gauze directly on the wound then wrapped it tight. Gauze absorbs blood and the blood will stick and dry to it. I'll follow up on this point soon. Then she did not give me a post-op shoe. She stuffed my sock back on my foot, then stuffed my foot into the boot I came in wearing. Which is a tad narrow because my feet at are a tad narrow, but they were no longer a tad narrow after swelling up my toe and putting a thick bandage on me. My big swollen toe was STUFFED into my tight shoe. Was as tight as possible. And I wasn't given a mobility aid. I walked myself to my car. I drove myself, not expecting this surgery. 

I was not prescribed antibiotics or anti-inflammatories, which I later learned is the gold standard of this surgery. No mobility aids. I was given bandages with padding smaller than the size of my nail bed. And told to go home and soak in epsom salt water. She told me to take aspirin or ibuprofen as needed... and let me tell you, I WISH I was given something stronger. I needed a lot over 3 weeks, which is so bad for my liver.

I made it home, pulled my boot off with a very uncomfortable tug, rested, and the numbing serum slowly wore off. I needed extra of it and it wore off within about 1.5 hours. I was told it could take up to the rest of the day to wear off, but no, that's not how my body is.  

Then it was time to change the bandage and soak in a foot bath. The gauze was glued to my wound, and I didn't know how bad it was going to be. She did put a thin amount of antibiotic gel over the cuticle, so it should have prevented the sticking, right? No, because the worst wound was up higher where the dead nail was attached. So I pulled at it a little. OUCH. I definitely swore loudly. So, not knowing what else to do, I sprayed it down with water until it detached. I was bleeding, but I did exactly what my instructions told me to do: put my foot into a foot bath with SALT. Epsom salt. To reduce swelling and clean it. An open wound on the most sensitive area of the body. In epsom salt. I screamed so loudly that I'm sure the entire block could hear me. I shook so hard from the shock of the pain that my husband had to hold me still. OUCH. OUCH. OUCH. No swear words were strong enough for that situation. 

But I continued to follow my instructions, and I put gauze on the wound and bandaged it. Guess what happened when I had to change that bandage? Yep. Screaming and crying.

So... the wound kept getting ripped open, despite my soaking the wrappings to peel them off. The wound couldn't heal. 

That's when I sought advice from friends who are medical professionals and got creative with the supplies I had.

My husband bought me whatever he could find at CVS. I couldn't do the foot baths for the first week, even without adding epsom salt. I tried and it had me in tears every time. So instead I sprayed iodine liberally all over my foot and the wound. I let it soak in, then I sprayed an antibiotic with lidocaine mix. I used witch hazel soaked pads with alcohol in them to clean all around the wound, but I couldn't touch the wound itself. Way too painful. Cleaning the wound with any pressure was going to have me in tears. 

I used extra large bandages and tented it over the nail bed, so that the pad could not touch the wound. That was the only method that was working for me. The trouble was when I accidently moved my toe in such a way that the padding did touch the wound, which was still bleeding after more than a week, and the padding stuck the wound... then rippped at it. There went any healing progress! I tried a different method of bandaging the wound with smaller bandages, and the adhesive touched the wound just enough that I couldn't rip it off.  The only way I could get the bandages off in both situations was to soak my whole foot in a foot bath. It stung like crazy! But eventually, after about 10 minutes each time, the bandages released and popped off into the water. And that's when I realized I was able to tolerate the foot baths well enough to do them to clean my toe out. But not with epsom salt. I used colloidal silver in the water instead. 

So I thought through it. I decided to put antibiotic gel directly only the pad of the bandages, and I painted it with a sterile pad to coat the entire pad. That worked to prevent the pad from sticking to the wound. That is what I should have been doing the whole time, and I never should have attempted a smaller bandage. 

But then... about 2 weeks into this nightmare, I started to get a lot of pus. White, not yellow, but a lot. Everyone told me it was time to see a doctor - a different doctor. I mailed my podiatrist photos of my pus covered toe on a Thursday evening, thinking I would get a response the next day. At 11 am the next day the message showed it was read, but I never got a reply (at all - not even by today.).

So by Friday afternoon I decided to go to the walk-in clinic, and it was a very good thing I did! The doctor was an ER doctor and the nurse had podiatry experience. Both excellent! I told them how I was I treated - I mean, not treated. They couldn't say much, but they did tell me how to take care of myself correctly. The nurse swabbed my toe bed to do a culture - OUCH OUCH OUCH. Holy @#$%^. And then the doctor put me on antibiotics. She attempted to put me on an anti-inflammatory, but I was allergic to all of them. She wrote me a note to prevent me from going to work and told me to get off my feet no matter what! The nurse taught me how to bandage properly, and even gave me scissors to cut bandages exactly right. Then she told me where to go to buy a proper pair of shoes to recover in (I'll get into the shoe issue in the next part of my blog.)

That was exactly 1 week ago. I took my antibiotics, got my proper shoes, bandaged correctly, got off my feet as much as possible, let it breathe more, was able to clean it in foot baths, and elevated it more often. In the last 48 hours I have FINALLY started to heal. I was at a 8-10/10 level of pain managed only with ibprofen for 2.5 weeks. In the last 48 hours the pain level went down gradually, and I haven't taken pain killers in this time. I now am at a 2-3/10 level of pain when resting, and it goes up to a 5/10 when touched or walking too much. The tenderness on the nail bed is 50% reduced. 


PART II: Complications and Solutions

Shoes:
MAKE SURE YOU GET A POST-OP SHOE BEFORE THIS SURGERY. Don't rely on your doctor to give you mobility aids. And trust me, you will need it. Think through this: you have to put all your body weight on your foot to walk, which increases pressure on the wound, which is on the most sensitive part of your body. Consider using a cane too. You're not being a baby. Keep weight off that toe if you want to heal!

I couldn't find a post-op shoe in town. I spent a week looking and asking around, and it meant I was hobbling around on the side of my foot without a shoe, which lead to ankle pain. All I could find were expensive boots for ankle recovery. I tried all the shoes I own. The ONLY shoe that I could make work was a Teva sandal, and it wasn't comfortable at all, but it was all I had. I went to work wearing that sandal and it was borderline not acceptable for all the walking I had to do. 

The nurse at the walk-in clinic sent me to The Uniform Center on 3rd street in Bismarck. Their new shoe store, Happy Soles, was phenomenal. The lady who helped me has been through the surgery too, and her daughter has POTS. She understood!! She was able to fit me in an open-toed slipper that's been saving me. It has a thick sole that isn't flexible, so it's keeping me stable, and I don't feel the ground. It has Velcro straps on top so that I don't have to slide in and out. I strap it on. It was a game changer for my recovery!!! The velcro is very impotent: I couldn't slide into slippers because of the size of the bandage and the pressure. I needed straps that come fully open so I could simply step onto the sole and then strap in. 

POTS: 
Okay - this really really really complicated issues. I wasn't prepared for the biggest issue at all: blood pooling in my feet.