Well, my fears regarding the nerve block wearing off were certainly legit... I spent the late evening and wee hours of the morning doing my best to sleep while worrying about the block wearing off. Then I woke up at 2am in quite a bit of pain. I quickly buzzed my night nurse, Alexa, and asked for pain pills ASAP. She informed me that I wasn't due for another dose until 3am. I tried to be patient... I was on Facebook and surfing the web, trying to distract myself; I tried the TV... It was all a giant fail and at 2:45am, I had to buzz the nurses again and beg for meds. I was in so much pain that I was shaking uncontrollably. The nurse gave me my pills right then, even though it was a few minutes early. Unfortunately, the pain had gotten so great that the oxycodone dose I was given did nothing to relieve the pain. At 4am, I gave up on the pills working and I buzzed the nurses again. I felt like such a pain but I didn't feel like I had any choice. The pain was the most intense thing I've ever felt. The nurse told me she'd see what she could do and eventually came back with a shot of Dilaudid which she gave me through my IV. At 5:30am, I finally got back to sleep. Unfortunately, at 6am, everyone started coming around - checking my vitals, drawing blood, etc. A resident from the orthopedic team came in to check on me - I informed him about the pain and how much trouble we had managing it... The resident told me that he'd authorize me to have twice as much of the pain meds to get it under control.
Sure enough, at 10:30 (my next schedule dose), I was given four pain pills instead of two. They KNOCKED ME OUT! I could hardly stay awake, my words were slurring, I felt like I couldn't feel my hands, and I was unbelievably weak. And in that state, PT decided to visit for the first time! He talked to me for a bit and then he wanted to get me out of bed. I told him how I was feeling and he said we'd try and do "what we can"... That turned out to be next to nothing. He got me seated on the side of the bed and I started to feel like I was going to pass out; my ears were ringing, the room was spinning, and I wasn't sure my head was actually attached to my shoulders... I told the therapist and he decided to take my blood pressure; it was a wonderful 83/39 (keep in mind, that the "normal" is supposed to be about 120/80). With a pressure that low, he told me it was time to lie back down! He assured me that he would be back...
Next, my mom and my "fake" sister (we grew up together but aren't actually related - she was my neighbor but feels more like my sister), Beth, came to visit around 11am. My mom had to actually feed me my sherbet and put the straw to my mouth to help me drink... It was sad... But the pain was finally starting to subside. My mom and Beth helped me get dressed which felt great - starting to feel like a human again! Soon after, Dr. M and a few of his residents stopped by. He was angered to hear that my pain had gotten out of control and that my nurses did just give me the Dilaudid immediately. He also was a bit concerned about my blood pressure being so low (it had been low throughout the night - not just during PT); he had the nurses hang another bag on my IV to get my pressure back up. Dr. M also got a resident to come by to take out my drain - he told me that some people say it doesn't feel like anything and others say it feels like a knife. Unfortunately for me - it felt like a knife! But the pain went away quickly...
The side effects of the pain meds started to wear off and the IV bag started to get my pressure better. By the time lunch rolled around, I was feeling much better. I still couldn't eat well though... I'm beginning to think that I'm never going to get my saliva back! The nurses said that the lack of saliva could be from the pain meds, not just the breathing tube so it looks like I could have this problem for a while. Anyway, lunch was a breaded baked chicken breast. I couldn't even chew it! Even with my new technique (stolen from competitive eaters) - I take a bite of food, take a sip of water, chew, and then I can finally swallow it! Aye... the things we must do! Anyway, I did my best to eat but ended up with a few sherbet cups instead...
Soon after I ate, my mom and Beth left and then the occupational therapist came to visit. She managed to sit me up on the side of the bed (no feelings of passing out), get me standing up with a walker (partial weight-bearing, of course), and get me to the bathroom. Ahhh - more things to make me feel human again... Then she put me into the recliner in my room so that I could try a new seat for a bit! I was in the recliner for about 15 minutes before I wanted to get back to bed... At which point, PT came back so no bed for me! This time, PT went much better - I was actually able to take a "walk" down the hall. Of course, due to my weight-bearing restrictions, I was only able to "touch" my left leg to the ground; but still, it felt like progress!
After PT left, my pastor and a family friend (who attends our church) came to visit for a bit. They stayed for a bit and soon it was time for dinner. This time I actually ate!! In all fairness, it was spaghetti and meatballs with broccoli, all of which doesn't require much saliva! Then the family (husband, mom, and dad) all came to visit! And now... it's time for me to get some sleep!
Thursday, December 8, 2011
Wednesday, December 7, 2011
Surgery Day.. Ahhh!
So, yesterday, I received a phone call telling me that I needed to be at the hospital at 8:30am for my surgery. That sounded good to me - I wouldn't have to be up too early but it wasn't so late that I would have time to stress or feel like I was starving! However, an hour later, I got a second call... The hospital representative asked if I could be there at 5:15am for my surgery!? Well, of course, I'll be there whatever time you say... But, holy cow! That's early!! My husband and I live about 45 minutes from the hospital so we decided to stay overnight at my parents' house last night so that we'd only be 20 minutes away. While it was still early, we only had to get up at about 4am - just enough time to get dressed, get the dogs out, and drive to the hospital (leaving time to get there early, of course).
So sure enough, I was here at the hospital around 5am. I checked in and waited in the same-day surgery waiting area for about 15 minutes before a hospital escort took a whole group of us up to a different waiting room. I was only allowed to take two people with me, so my mom and my husband accompanied me and my dad waited in the surgical waiting area. We waited for less than five minutes before my name was called - this time only one person was allowed to come with me (obviously, I choose my husband). I was given a gown to change into and was told to give a urine sample (which I later found out was for a pregnancy test - just in case!). After all that, a nurse came in to ask a million and two questions - I am pretty sure I confirmed my name, type of surgery, surgical leg, and allergies at least fifty times!
My first sign that this was all for real and that I was actually about to have the surgery was when the anesthesiologist stopped by. I've known Dr. High for a long time - his son graduated with me and his daughter was a few years younger but she played high school soccer with me. He stopped by just to make sure I was doing okay, that I wasn't too nervous, and to let me know that the nerve block team would be in to see me soon... And sure enough, they were! It was less than five minutes later and Dr. G and his team came in. They made sure I understood the nerve block procedure and said that they would be doing the block shortly; one of the residents then put in an IV for me - shockingly, she got it in the back of my hand with no trouble at all (I've been told I'm a "hard stick" and usually they end up choosing a different site). Dr. G and his team came back in with everything they needed for the block and got to work. I have to say - the block was NOTHING! As in, hardly felt like anything - easy as anything! And it sure did work... They numbed the skin with local anesthesia and then they position the needle approximately and use the ultrasound machine to ensure the needle is as close to the nerve as possible. The first nerve they did was the femoral nerve. They warned me that when they got close my leg would jump (and they had to get that close or the block wouldn't work); let me tell you, even though I was warned, it startled me at first (luckily they had given me quite a bit of pain killers and a sedative before the procedure so I didn't freak out or anything) - my leg literally JUMPED off the table! The second block was for the sciatic nerve and for that one, when the needle got close enough, my foot would twitch like crazy. But, all in all, there was a tiny bit of pain from the original needle stick and some discomfort as the needle moved, but no real pain at all. And certainly worth it - my leg started to go completely numb in about five minutes and within fifteen minutes it was completely dead!
After that, it was just time to wait to go into the OR. My mom was brought in to see me before I was wheeled away and it was good to see her first. She helped distract me! Finally, at about 7:30am, I was wheeled into the operating room. It only took a minute before they had the mask on me and I was being put to sleep! Next thing I knew, I was waking up... It seemed like a long night's sleep, but not very restful. I was in the weirdest recovery room I've ever seen (and I've seen several)... Instead of a large recovery room, it was a smaller room, maybe off the side from the recovery room - I'm not sure (they had taken my glasses and I couldn't see far from my bed). The room had four bed areas but I was the only one there at first and I didn't even see any nurses at first. Finally, someone came over to check on me and, next thing I knew, they were telling me that I was being taken to my room. I was shocked that they were taking me up already since I could hardly open my eyes... But sure enough, I was in my room in no time. My family was there waiting for me; they stuck around for a bit and then left me around noon so I could get some sleep. My nurse, Julie, offered to get me some food; she offered me the liquid tray (broth, Jello, etc.) or the soft foods tray (soup, pudding, etc.) - I chose the soft foods tray... However, what actually came was a full roast beef dinner! I was only able to eat the mashed potatoes since I had no saliva due to the breathing tube... Julie yelled at the food services people who then did bring me that soft foods tray while I was sleeping - then they took it away before I even woke up!
So after I had enough sleep, I decided to check my Facebook... only to see a post from my mom, updating everyone on my surgery! And how interesting - from that post I learned there was a complication during my surgery! What a way to find out, eh?! Apparently, one of the screws from my ACL reconstruction surgery was in the way of the tibial component. Dr. M said that he probably could have left it in, but the component could have loosened quicker or the screw could cause the component to wear out quicker! However, when Dr. M removed the screw, the bone surrounding it came with it, leaving a 1/2-inch hole in the bone. He had to fill the hole with fragments of my bone... Unfortunately, it also means that I will only be "partial weight-bearing" until the hole heals. I'm not really sure what the partial weight-bearing status means but I guess I'll find out soon... Next fun part? I called my sister-in-law, Katelin, to tell her how I was doing. I told her about reading my mom's Facebook post and she asked how I felt about the doctor's suggestion that I take a semester off... Say what?! Of course, that was the way that I learned that my doctor thought the complication would make it extra difficult for me to go back for my last semester of law school this spring. I'm not sure what I'm going to do on that front... Only time will tell!
Late in the afternoon, my family came back up. Dinner came and I was unable to eat that either... It was pork chops, green beans, and mashed potatoes (again). Instead, I ate a few cups of sherbet! Just recently, around 6pm, I started to feel the first twinges of pain in my knee. I'm not looking forward to the block wearing off. I'm not really feeling any real pain, just twinges here and there. I still can't feel (or move) my toes yet so I'm hoping I have a while before the block is worn off completely. I'm just worried about how it will go when the block wears off and how much pain I'll be in. I was warned by the doctor and the anesthesia team that I need to alert the nurses as soon as I start to feel real pain so that they can give me oral pain meds to make sure the pain doesn't get out of hand... Here's to hoping it all goes well!
So sure enough, I was here at the hospital around 5am. I checked in and waited in the same-day surgery waiting area for about 15 minutes before a hospital escort took a whole group of us up to a different waiting room. I was only allowed to take two people with me, so my mom and my husband accompanied me and my dad waited in the surgical waiting area. We waited for less than five minutes before my name was called - this time only one person was allowed to come with me (obviously, I choose my husband). I was given a gown to change into and was told to give a urine sample (which I later found out was for a pregnancy test - just in case!). After all that, a nurse came in to ask a million and two questions - I am pretty sure I confirmed my name, type of surgery, surgical leg, and allergies at least fifty times!
My first sign that this was all for real and that I was actually about to have the surgery was when the anesthesiologist stopped by. I've known Dr. High for a long time - his son graduated with me and his daughter was a few years younger but she played high school soccer with me. He stopped by just to make sure I was doing okay, that I wasn't too nervous, and to let me know that the nerve block team would be in to see me soon... And sure enough, they were! It was less than five minutes later and Dr. G and his team came in. They made sure I understood the nerve block procedure and said that they would be doing the block shortly; one of the residents then put in an IV for me - shockingly, she got it in the back of my hand with no trouble at all (I've been told I'm a "hard stick" and usually they end up choosing a different site). Dr. G and his team came back in with everything they needed for the block and got to work. I have to say - the block was NOTHING! As in, hardly felt like anything - easy as anything! And it sure did work... They numbed the skin with local anesthesia and then they position the needle approximately and use the ultrasound machine to ensure the needle is as close to the nerve as possible. The first nerve they did was the femoral nerve. They warned me that when they got close my leg would jump (and they had to get that close or the block wouldn't work); let me tell you, even though I was warned, it startled me at first (luckily they had given me quite a bit of pain killers and a sedative before the procedure so I didn't freak out or anything) - my leg literally JUMPED off the table! The second block was for the sciatic nerve and for that one, when the needle got close enough, my foot would twitch like crazy. But, all in all, there was a tiny bit of pain from the original needle stick and some discomfort as the needle moved, but no real pain at all. And certainly worth it - my leg started to go completely numb in about five minutes and within fifteen minutes it was completely dead!
After that, it was just time to wait to go into the OR. My mom was brought in to see me before I was wheeled away and it was good to see her first. She helped distract me! Finally, at about 7:30am, I was wheeled into the operating room. It only took a minute before they had the mask on me and I was being put to sleep! Next thing I knew, I was waking up... It seemed like a long night's sleep, but not very restful. I was in the weirdest recovery room I've ever seen (and I've seen several)... Instead of a large recovery room, it was a smaller room, maybe off the side from the recovery room - I'm not sure (they had taken my glasses and I couldn't see far from my bed). The room had four bed areas but I was the only one there at first and I didn't even see any nurses at first. Finally, someone came over to check on me and, next thing I knew, they were telling me that I was being taken to my room. I was shocked that they were taking me up already since I could hardly open my eyes... But sure enough, I was in my room in no time. My family was there waiting for me; they stuck around for a bit and then left me around noon so I could get some sleep. My nurse, Julie, offered to get me some food; she offered me the liquid tray (broth, Jello, etc.) or the soft foods tray (soup, pudding, etc.) - I chose the soft foods tray... However, what actually came was a full roast beef dinner! I was only able to eat the mashed potatoes since I had no saliva due to the breathing tube... Julie yelled at the food services people who then did bring me that soft foods tray while I was sleeping - then they took it away before I even woke up!
So after I had enough sleep, I decided to check my Facebook... only to see a post from my mom, updating everyone on my surgery! And how interesting - from that post I learned there was a complication during my surgery! What a way to find out, eh?! Apparently, one of the screws from my ACL reconstruction surgery was in the way of the tibial component. Dr. M said that he probably could have left it in, but the component could have loosened quicker or the screw could cause the component to wear out quicker! However, when Dr. M removed the screw, the bone surrounding it came with it, leaving a 1/2-inch hole in the bone. He had to fill the hole with fragments of my bone... Unfortunately, it also means that I will only be "partial weight-bearing" until the hole heals. I'm not really sure what the partial weight-bearing status means but I guess I'll find out soon... Next fun part? I called my sister-in-law, Katelin, to tell her how I was doing. I told her about reading my mom's Facebook post and she asked how I felt about the doctor's suggestion that I take a semester off... Say what?! Of course, that was the way that I learned that my doctor thought the complication would make it extra difficult for me to go back for my last semester of law school this spring. I'm not sure what I'm going to do on that front... Only time will tell!
Late in the afternoon, my family came back up. Dinner came and I was unable to eat that either... It was pork chops, green beans, and mashed potatoes (again). Instead, I ate a few cups of sherbet! Just recently, around 6pm, I started to feel the first twinges of pain in my knee. I'm not looking forward to the block wearing off. I'm not really feeling any real pain, just twinges here and there. I still can't feel (or move) my toes yet so I'm hoping I have a while before the block is worn off completely. I'm just worried about how it will go when the block wears off and how much pain I'll be in. I was warned by the doctor and the anesthesia team that I need to alert the nurses as soon as I start to feel real pain so that they can give me oral pain meds to make sure the pain doesn't get out of hand... Here's to hoping it all goes well!
Saturday, December 3, 2011
Great site about the surgery
I wanted to share this website with everyone as well. The site allows you to complete a virtual knee replacement. You will mark the incision, use a scalpel to cut open the incision, retract the tissue, use jigs to insure bone cuts are proper, use a bone saw, fit the components, cement the components, and close up the wound. You actually see the process (on a graphic rather than an actual person) and have a full understanding of the steps by the time you are done. There is also a tab to click on actual surgical pictures for anyone who might be interested (i.e. not the squeamish).
http://www.edheads.org/activities/knee/
http://www.edheads.org/activities/knee/
Pre-op Class
Dr. M requires all of his patients attend the joint replacement pre-op class; for me, that class was this past Thursday (two days ago). The class is about two hours long. Here is the basic overview: the first hour (minus a few introductory minutes) was Dr. M telling the patients about both hip and knee replacements (both types of patients attend the same class), showing us models, telling us what to expect, and (again) explaining the risks. After Dr. M, we heard from a physical therapist who gave a basic overview of the exercises we will be doing in the hospital and some general info. Next, we heard from an occupational therapist - but her presentation had no relevance for the knee patients, just the hip patients (gadgets to help them get dressed). Third, a nurse from the anesthesia and pain management team explained the regional nerve blocks as well as the pain management "cocktail" we will be given after surgery. Finally, a nurse from the surgical team gave some instructions as to what we need to do before the date or surgery and provided some information on discharge planning.
Now for more detail... Dr. M showed us the knee joint pre-op, showed how the bone is removed, and showed how the components are inserted. He then took questions. I found out that I will be in the hospital for 3 days and 2 nights; since my surgery is Wednesday, I will be going home Friday (barring no complications). I learned that he uses plastic dissolving stitches internally rather than the traditional sutures or staples; his reasoning is not cosmetic (although it reduces scarring) but rather that it gives a water-tight seal so that the patient knows that if there is drainage to call in (rather than telling a patient to call about "unusual" drainage when the patient has no idea what's normal). This also means that when the wound is dry, I can shower! No waiting two weeks to get a real shower - so exciting! (Though it doesn't help me in getting TO the shower which is on the second floor of my home.) Dr. M also told us that we will have some sort of strip over the incision and we can just let it there until it falls off (or until the 2-week appointment when he will take them off). Of particular interest, he mentioned that he does not use CPM (continuous passive motion) machines. He told us that he was trained to use them, but during his fellowship at Duke they didn't use the CPM machines and he saw no difference. There was no improvement for patients on the machine but there is some risks. He told us about two different patients: one patient had a spinal and could not feel his legs so when his foot was rubbing against the side of the machine, no one knew and he eventually had to have the leg amputated (an ulcer formed on the outside of his foot, got infected, and wouldn't heal); another patient's machine was set to the wrong specifications which bent her knee too far, damaged the parts, and she wasn't able to have a revision due to the massive tearing of tissue. On another, similar, note, he also warned us to make sure we have a pillow under our heels - we will have a regional nerve block and won't be able to feel pressure sores in the making and the heels are very vulnerable.
Dr. M also discussed what he considered the biggest, most important risks. 1) Death - There is also a risk of death when undergoing surgery. 2) Infection - We learned the average rate of infection (over one's lifetime) is about 1-2% but the rate doubles for diabetics and increases exponentially for people with Hepatitis C (about 20% risk). Infection can be hard to detect because the knee won't necessarily turn red or swell, but can often just cause pain; since a joint replacement is painful as is, it can be hard to determine the reason for the pain. If infection is suspected, a blood test will be performed - if the blood test is positive, the doctor will test the joint fluid. If there is an infection, they usually need to remove the metal parts for three months and then do another surgery to put them back in. Usually just washing out the joint doesn't work because the bacteria (the risk of infection is of a bacterial infection, not a viral infection) can live in the bio film on the components; Dr. M analogized to fighting with you back against a wall - it's easier to fight when you can only be attacked from the front. It is this risk of infection that requires patients to take antibiotics before a trip to the dentist (even for routine teeth cleaning) or before a colonoscopy (though I have a while before I need one of those!) or really anything where bacteria could get into the bloodstream. It is also important to go to the doctor right away with a urinary tract infections, pneumonia, or any other sickness resulting from bacteria (i.e. not the common cold or the flu which are both viruses). 3) Fracture - The drilling and bone sawing required can cause fractures within the bones. The risk is about 1-2% and are generally treated with screws or cables (in the case of a large fracture of the femur during a hip replacement, the doctor may use plates and screws as well). 4) Loosening of the parts - The plastic parts wear down and can eventually loosen; it is estimated that this will be 10-20 years down the road but the time may be shorter for younger patients who will generally be more active. However, the plastics used now have shown some potential to last longer than expected. But, when you are 26, it is pretty much a certainty that the parts will wear out within my lifetime (provided a live a long, healthy life). 5) Blood clots - Any person who remains sedentary can get blood clots, especially in the legs, but when you have just had surgery and have limited mobility, the risk increases. A blood clot that forms in the leg is called a deep vein thrombosis; this is very painful and will cause swelling. The clot can dislodge and travel through the body, causing more damage or even death; if the clot goes to the lungs, you can have a pulmonary embolism which is the blockage of the main artery of the lung or one of its branches. The blockage of blood flow to the lungs will cause difficulty breathing and chest pain; a minor embolism will leave the patient short of breath but a larger embolism can cause sudden death. In fact, pulmonary emboli are the biggest risk of death following a knee replacement. To prevent blood clots, patients are encouraged to walk as early as possible, wear compression socks, use leg pumps (which use air pressure to squeeze the lower legs to improve blood flow) at least 20 hours per day, and take blood thinners. Dr. M prescribes Lovenox which is an injectable blood thinner - we will learn to give ourselves a subcutaneous injection in the stomach once per day; Lovenox has less complications than the well-known coumadin (or warfarin) - you don't have to worry about various foods that counteract the drug and there are less risks of internal bleeding, etc. We will use the Lovenox for 3 weeks, followed by 3 weeks of aspirin. 6) Limp - A persistent or permanent limp can develop due to range of motion issues or misalignment. 7) Instability - Any revision of a joint can result in less-than-perfect stability. 8) Persistent pain - For me, however, I'm already in persistent pain so this doesn't seem like much of a risk. 9) Loss of motion - Scar tissue can build up in the joint and prevent the patient from achieving a good range of motion (usually a patient should expect to achieve full extension -0 degrees- and should be able to get about 130 degrees bending). If scar tissue becomes a problem, the surgeon will put you under anesthesia at about six weeks post-op and manipulate the joint, forcing it to bend and extend to break up any scar tissue.
On to a cheerier topic - the physical therapist told us that we will be up and walking within 24-hours and will have two sessions of physical therapy per day (while in the hospital). We will be told to do certain exercises on our own about five times per day. Knowing me, I'll probably do them even more than required. First of all, I want a speedy recovery - I only have four weeks before school starts up again. Second, the requirements are for someone much older than myself. I can push myself harder than that... The therapist also told us that it is expected that we will have full extension and about a 90-degree bend before leaving the hospital. The occupational therapist didn't have much to say to the knee patients but did tell us that (since they want us bending as much as possible) we don't get any fun gadgets to help us get dressed; we also learned that the morning after surgery, occupational therapy will be in to make use get dressed, to show that we can start to become self-sufficient.
As I mentioned, a nurse from the anesthesia and pain management team also talked to us. She explained that knee patients will get two sets of regional nerve blocks - one will be for the femoral nerve and the other will be for the sciatic nerve. The nerve block is a series of injections placed very close to the nerve to cut off sensation. A perfect nerve block will make the leg completely numb while an imperfect block will knock out much of the pain but you will still feel some discomfort. We were also told that we would start a drug "cocktail" - there will be three "pain" medicines: Oxycontin (or, generic, oxycodone), Celebrex (anti-inflammatory), and the maximum dose of Tylenol. We will stop the Oxycontin after 3-5 days after leaving the hospital, the Celebrex about 2 weeks after leaving the hospital, and the Tylneol about a week after leaving the hospital. We were also told that we would be given two pills to counteract the side effects of the pain meds - a drug to help deal with nausea caused by the three drugs and a stool softener to prevent the constipation often caused by narcotics.
Finally, the nurse from the surgical team explained a night-before cleansing wipe routine (we were given six large germicidal wipes that we clean different areas of our body with so that, when all are used, our entire body will be cleaned; the wipes are to be used at least two hours after bathing and are said to reduce the chances of infection). We were also told that we needed to make an appointment for our first physical therapy outside the hospital, to get clearance from both our primary care physician and dentist, and to get blood and urine lab work done. The nurse started talking about discharge planning but I had to head to my anesthesia appointment (or so I thought...); I wasn't worried about missing anything since the information is in a packet and I know that I won't need to consider a skilled nursing care facility or nursing home. I am lucky enough to have a mother who doesn't work and lives close by; I will be living with my parents for the week or two after surgery until I can take care of myself enough to go home (my husband will also be staying there).
Anyway, so off to anesthesia I go... Only to be informed that my 11am appointment had been changed to 1:30pm and I wasn't notified. Luckily I thought to ask to get my scripts for the lab work; after filling out a form and waiting for a practitioner to check it over, I got my scripts for a chest X-ray, urinalysis, and blood work. Because I had just gone to the bathroom, I chose to do the X-ray first which was quick and easy. Then it was off to the lab - of course they wanted to do the urine sample first so luckily I had been drinking lots of water. Finally it was time for blood work. Blood and needles don't bother me... I don't like to see the needle go into my skin, but other than that, I'm usually good. But I didn't take into account that all I had to eat was a granola bar almost 6 hours prior to blood work (it was lunchtime). The girl taking my blood was a student and she had some problem getting any blood to come out (I have the bruise to show for it); I'm not sure whether it was the lack of food, the amount of time the blood draw was taking, or a combination, but I started to feel it... I was getting light-headed and dizzy as she put the bandage on my air. Then I heard this pounding and it sounded like I was listening to everything through water. I've never passed out before but I knew I was about to if we didn't do something quick - she escorted me to lie on a bed, then gave me an icepack to put on the back of my neck. Just lying down for a few seconds seemed to solve everything - by the time she came back with some juice, I was ready to sit up and leave. But, lesson learned, just like you don't donate blood on an empty stomach, don't get blood work done on an empty stomach! So after that near-disaster, my mom (who was nice enough to come along for all of this) and I grabbed some lunch before heading back for that rescheduled anesthesia appointment.
I think I'm the anesthesia team's dream... I have no health problems (besides the knee), no problems with anesthesia, no drug allergies besides Synvisc (a knee injections), no food allergies, and no latex allergies. I have had so many surgeries that I know where the best spot to put my IV is and I know to ask for anti-nausea medicine and Demerol in the recovery room. (I will be sad that, since I'm inpatient, my family won't be able to be with me in the recovery room.) Anyway, so the anesthesia team did a basic physical, asked a bunch of questions, and gave me my final instructions (no food after midnight, take a Pepcid the night before and a Pepcid in the morning, no jewelry or make-up, and wear my glasses instead of contacts).
All that was left was getting the clearances from my primary care physician and my dentist... But this proved more difficult than expected! First, we headed to the dentist. But I'm bad and haven't been in two years so before they would sign, I needed an exam! But this was Thursday - six days before surgery, two of which are the weekend and two are the days of my finals! Well, luckily, one of the hygienists was able to squeeze me in for an exam, but not a cleaning, so I got my form signed. But next we headed to the primary care physician's office. Well, I hadn't been there in over a year (last time was for a sinus infection) so they won't sign it either. To make matters worse, the last several doctors (of P.A.s) that I saw don't work there anymore! Oh, and did I mention that the office was about to close for the day and wasn't open on Friday or Saturday because they are moving locations? With no hope of getting that clearance, I had to call Dr. M's office and beg for a waiver. Luckily they called me the next morning to tell me that since my anesthesia appointment went really well that they would not require the clearance but would send all the info to my primary care physician for him to review and if he had any concerns he can call them (which I'm sure he won't since whoever reviews it probably has never even seen me).
So, where am I now? I'm four days away from surgery and I have everything set up - all of my appointments are done and all of my forms are filled out. I just need to get through my two finals on Monday and Tuesday! Then comes the last minute planning (until I know what time my surgery is on Wednesday, I can't plan for someone to take care of my dogs) and packing. I need to pack a bag for the hospital and I also need to pack a bag (or two) for my one-to-two week stay at my parents! I'm almost ready and can't wait to get the hard part over with...
Now for more detail... Dr. M showed us the knee joint pre-op, showed how the bone is removed, and showed how the components are inserted. He then took questions. I found out that I will be in the hospital for 3 days and 2 nights; since my surgery is Wednesday, I will be going home Friday (barring no complications). I learned that he uses plastic dissolving stitches internally rather than the traditional sutures or staples; his reasoning is not cosmetic (although it reduces scarring) but rather that it gives a water-tight seal so that the patient knows that if there is drainage to call in (rather than telling a patient to call about "unusual" drainage when the patient has no idea what's normal). This also means that when the wound is dry, I can shower! No waiting two weeks to get a real shower - so exciting! (Though it doesn't help me in getting TO the shower which is on the second floor of my home.) Dr. M also told us that we will have some sort of strip over the incision and we can just let it there until it falls off (or until the 2-week appointment when he will take them off). Of particular interest, he mentioned that he does not use CPM (continuous passive motion) machines. He told us that he was trained to use them, but during his fellowship at Duke they didn't use the CPM machines and he saw no difference. There was no improvement for patients on the machine but there is some risks. He told us about two different patients: one patient had a spinal and could not feel his legs so when his foot was rubbing against the side of the machine, no one knew and he eventually had to have the leg amputated (an ulcer formed on the outside of his foot, got infected, and wouldn't heal); another patient's machine was set to the wrong specifications which bent her knee too far, damaged the parts, and she wasn't able to have a revision due to the massive tearing of tissue. On another, similar, note, he also warned us to make sure we have a pillow under our heels - we will have a regional nerve block and won't be able to feel pressure sores in the making and the heels are very vulnerable.
Dr. M also discussed what he considered the biggest, most important risks. 1) Death - There is also a risk of death when undergoing surgery. 2) Infection - We learned the average rate of infection (over one's lifetime) is about 1-2% but the rate doubles for diabetics and increases exponentially for people with Hepatitis C (about 20% risk). Infection can be hard to detect because the knee won't necessarily turn red or swell, but can often just cause pain; since a joint replacement is painful as is, it can be hard to determine the reason for the pain. If infection is suspected, a blood test will be performed - if the blood test is positive, the doctor will test the joint fluid. If there is an infection, they usually need to remove the metal parts for three months and then do another surgery to put them back in. Usually just washing out the joint doesn't work because the bacteria (the risk of infection is of a bacterial infection, not a viral infection) can live in the bio film on the components; Dr. M analogized to fighting with you back against a wall - it's easier to fight when you can only be attacked from the front. It is this risk of infection that requires patients to take antibiotics before a trip to the dentist (even for routine teeth cleaning) or before a colonoscopy (though I have a while before I need one of those!) or really anything where bacteria could get into the bloodstream. It is also important to go to the doctor right away with a urinary tract infections, pneumonia, or any other sickness resulting from bacteria (i.e. not the common cold or the flu which are both viruses). 3) Fracture - The drilling and bone sawing required can cause fractures within the bones. The risk is about 1-2% and are generally treated with screws or cables (in the case of a large fracture of the femur during a hip replacement, the doctor may use plates and screws as well). 4) Loosening of the parts - The plastic parts wear down and can eventually loosen; it is estimated that this will be 10-20 years down the road but the time may be shorter for younger patients who will generally be more active. However, the plastics used now have shown some potential to last longer than expected. But, when you are 26, it is pretty much a certainty that the parts will wear out within my lifetime (provided a live a long, healthy life). 5) Blood clots - Any person who remains sedentary can get blood clots, especially in the legs, but when you have just had surgery and have limited mobility, the risk increases. A blood clot that forms in the leg is called a deep vein thrombosis; this is very painful and will cause swelling. The clot can dislodge and travel through the body, causing more damage or even death; if the clot goes to the lungs, you can have a pulmonary embolism which is the blockage of the main artery of the lung or one of its branches. The blockage of blood flow to the lungs will cause difficulty breathing and chest pain; a minor embolism will leave the patient short of breath but a larger embolism can cause sudden death. In fact, pulmonary emboli are the biggest risk of death following a knee replacement. To prevent blood clots, patients are encouraged to walk as early as possible, wear compression socks, use leg pumps (which use air pressure to squeeze the lower legs to improve blood flow) at least 20 hours per day, and take blood thinners. Dr. M prescribes Lovenox which is an injectable blood thinner - we will learn to give ourselves a subcutaneous injection in the stomach once per day; Lovenox has less complications than the well-known coumadin (or warfarin) - you don't have to worry about various foods that counteract the drug and there are less risks of internal bleeding, etc. We will use the Lovenox for 3 weeks, followed by 3 weeks of aspirin. 6) Limp - A persistent or permanent limp can develop due to range of motion issues or misalignment. 7) Instability - Any revision of a joint can result in less-than-perfect stability. 8) Persistent pain - For me, however, I'm already in persistent pain so this doesn't seem like much of a risk. 9) Loss of motion - Scar tissue can build up in the joint and prevent the patient from achieving a good range of motion (usually a patient should expect to achieve full extension -0 degrees- and should be able to get about 130 degrees bending). If scar tissue becomes a problem, the surgeon will put you under anesthesia at about six weeks post-op and manipulate the joint, forcing it to bend and extend to break up any scar tissue.
On to a cheerier topic - the physical therapist told us that we will be up and walking within 24-hours and will have two sessions of physical therapy per day (while in the hospital). We will be told to do certain exercises on our own about five times per day. Knowing me, I'll probably do them even more than required. First of all, I want a speedy recovery - I only have four weeks before school starts up again. Second, the requirements are for someone much older than myself. I can push myself harder than that... The therapist also told us that it is expected that we will have full extension and about a 90-degree bend before leaving the hospital. The occupational therapist didn't have much to say to the knee patients but did tell us that (since they want us bending as much as possible) we don't get any fun gadgets to help us get dressed; we also learned that the morning after surgery, occupational therapy will be in to make use get dressed, to show that we can start to become self-sufficient.
As I mentioned, a nurse from the anesthesia and pain management team also talked to us. She explained that knee patients will get two sets of regional nerve blocks - one will be for the femoral nerve and the other will be for the sciatic nerve. The nerve block is a series of injections placed very close to the nerve to cut off sensation. A perfect nerve block will make the leg completely numb while an imperfect block will knock out much of the pain but you will still feel some discomfort. We were also told that we would start a drug "cocktail" - there will be three "pain" medicines: Oxycontin (or, generic, oxycodone), Celebrex (anti-inflammatory), and the maximum dose of Tylenol. We will stop the Oxycontin after 3-5 days after leaving the hospital, the Celebrex about 2 weeks after leaving the hospital, and the Tylneol about a week after leaving the hospital. We were also told that we would be given two pills to counteract the side effects of the pain meds - a drug to help deal with nausea caused by the three drugs and a stool softener to prevent the constipation often caused by narcotics.
Finally, the nurse from the surgical team explained a night-before cleansing wipe routine (we were given six large germicidal wipes that we clean different areas of our body with so that, when all are used, our entire body will be cleaned; the wipes are to be used at least two hours after bathing and are said to reduce the chances of infection). We were also told that we needed to make an appointment for our first physical therapy outside the hospital, to get clearance from both our primary care physician and dentist, and to get blood and urine lab work done. The nurse started talking about discharge planning but I had to head to my anesthesia appointment (or so I thought...); I wasn't worried about missing anything since the information is in a packet and I know that I won't need to consider a skilled nursing care facility or nursing home. I am lucky enough to have a mother who doesn't work and lives close by; I will be living with my parents for the week or two after surgery until I can take care of myself enough to go home (my husband will also be staying there).
Anyway, so off to anesthesia I go... Only to be informed that my 11am appointment had been changed to 1:30pm and I wasn't notified. Luckily I thought to ask to get my scripts for the lab work; after filling out a form and waiting for a practitioner to check it over, I got my scripts for a chest X-ray, urinalysis, and blood work. Because I had just gone to the bathroom, I chose to do the X-ray first which was quick and easy. Then it was off to the lab - of course they wanted to do the urine sample first so luckily I had been drinking lots of water. Finally it was time for blood work. Blood and needles don't bother me... I don't like to see the needle go into my skin, but other than that, I'm usually good. But I didn't take into account that all I had to eat was a granola bar almost 6 hours prior to blood work (it was lunchtime). The girl taking my blood was a student and she had some problem getting any blood to come out (I have the bruise to show for it); I'm not sure whether it was the lack of food, the amount of time the blood draw was taking, or a combination, but I started to feel it... I was getting light-headed and dizzy as she put the bandage on my air. Then I heard this pounding and it sounded like I was listening to everything through water. I've never passed out before but I knew I was about to if we didn't do something quick - she escorted me to lie on a bed, then gave me an icepack to put on the back of my neck. Just lying down for a few seconds seemed to solve everything - by the time she came back with some juice, I was ready to sit up and leave. But, lesson learned, just like you don't donate blood on an empty stomach, don't get blood work done on an empty stomach! So after that near-disaster, my mom (who was nice enough to come along for all of this) and I grabbed some lunch before heading back for that rescheduled anesthesia appointment.
I think I'm the anesthesia team's dream... I have no health problems (besides the knee), no problems with anesthesia, no drug allergies besides Synvisc (a knee injections), no food allergies, and no latex allergies. I have had so many surgeries that I know where the best spot to put my IV is and I know to ask for anti-nausea medicine and Demerol in the recovery room. (I will be sad that, since I'm inpatient, my family won't be able to be with me in the recovery room.) Anyway, so the anesthesia team did a basic physical, asked a bunch of questions, and gave me my final instructions (no food after midnight, take a Pepcid the night before and a Pepcid in the morning, no jewelry or make-up, and wear my glasses instead of contacts).
All that was left was getting the clearances from my primary care physician and my dentist... But this proved more difficult than expected! First, we headed to the dentist. But I'm bad and haven't been in two years so before they would sign, I needed an exam! But this was Thursday - six days before surgery, two of which are the weekend and two are the days of my finals! Well, luckily, one of the hygienists was able to squeeze me in for an exam, but not a cleaning, so I got my form signed. But next we headed to the primary care physician's office. Well, I hadn't been there in over a year (last time was for a sinus infection) so they won't sign it either. To make matters worse, the last several doctors (of P.A.s) that I saw don't work there anymore! Oh, and did I mention that the office was about to close for the day and wasn't open on Friday or Saturday because they are moving locations? With no hope of getting that clearance, I had to call Dr. M's office and beg for a waiver. Luckily they called me the next morning to tell me that since my anesthesia appointment went really well that they would not require the clearance but would send all the info to my primary care physician for him to review and if he had any concerns he can call them (which I'm sure he won't since whoever reviews it probably has never even seen me).
So, where am I now? I'm four days away from surgery and I have everything set up - all of my appointments are done and all of my forms are filled out. I just need to get through my two finals on Monday and Tuesday! Then comes the last minute planning (until I know what time my surgery is on Wednesday, I can't plan for someone to take care of my dogs) and packing. I need to pack a bag for the hospital and I also need to pack a bag (or two) for my one-to-two week stay at my parents! I'm almost ready and can't wait to get the hard part over with...
Wednesday, November 30, 2011
One Week until Surgery
Well, it's almost that time! One week from now, I will be (hopefully) out of surgery and dealing with a new type of pain. My surgery is on December 7th, a day that will live in infamy (for me) for two reasons now. I won't know what time my surgery will be; I will only get a phone call the day before. But I am hoping for an early surgery. I know it's petty with everything else going on, but I hate not being able to eat the day of surgery; it just makes me miserable beforehand and makes my stomach upset as I come out of anesthesia. However, my multiple surgeries over the years has thought me a few things: 1) tell them before surgery that I will need the anti-nausea medicines post-op and they will give it to you before you even wake up, 2) pick apple juice in the recovery room over ginger ale or anything carbonated because carbonation on an empty stomach is not pleasant, and 3) ask for Demerol in the recovery room (I get the shakes as I come out of anesthesia and the Demerol helps with that and doesn't make me nauseous).
As you can probably guess, I am both excited and nervous. I think both of these are normal emotions for my situation... I'm excited to finally have this much-needed surgery and, hopefully, get my knee pain to a manageable (or nonexistent) level so that I can lead a normal life. I'm hopeful that, since I'm so young, that I will be able to live the rest of my life with my metal knee and do pretty much everything that my peers are doing. I would love to have the severe daily restrictions be a distant memory... I can't wait to climb the stairs whenever I need to, to make plans to go places without worrying that I'll be in too much pain to go, and to be able to exercise again. And one of the things I'm most excited about: actually being able to enjoy myself and not have to fake things! I've had to put on the "happy face" and do all sorts of things (ex. honeymoon excursions, charity walks, trips to amusement parks, etc.) when I've been in enough pain to take pretty much take away all my enjoyment. I guess I've done a good job though, maybe too good of a job... I've had a lot of peers at school say that they didn't know my knee was that bad because I just don't complain about it; I've had family members seem to underestimate my problems because I put on the "happy face" and don't bother talking about the pain (it just doesn't seem right to put it on everyone else).
But, as I mentioned, I'm also nervous... It seems to me that anyone going through a knee replacement should be nervous! A surgeon is about to slice open my whole knee, cut out a bunch of bone, and insert foreign objects. My advice: don't ever watch a video of a knee replacement or (God forbid) have shadowed a surgeon during the operation. Unfortunately, I've done both. While I feel well-educated, it makes things a bit scarier to have seen a bone saw in action and to see the pounding required to put in the replacement. But the thing that makes me the most nervous is the uncertainty. No one can give me stats on this surgery in someone my age. I could be facing a knee fusion or lower leg amputation at any point due to infection, a failed revision, or impossible revision. And, worst of all, I can't be sure what my level of pain will be after the surgery - it is expected that the pain will be greatly lessened but no one can make that guarantee and the worst thing I can think of (worse than amputation even) would be to have to continue to live at this level of pain or even greater pain for the rest of my life.
Well, we shall see! I will do my best to continue the updates... I have my pre-operative "class" tomorrow and my appointment with anesthesia (I did find out that an anesthesiologist that I know is available next Wednesday and I can request him for him surgery!) tomorrow morning. I'm excited to get my final questions answered... And then? It's back to my law school final exams! I have one final exam next Monday and one on Tuesday (then surgery on Wednesday); luckily I had an externship which is complete, a seminar which required writing a 30-page paper that is already turned in, and Advocacy which requires small assignments throughout the semester that are all finished. Until next time...
As you can probably guess, I am both excited and nervous. I think both of these are normal emotions for my situation... I'm excited to finally have this much-needed surgery and, hopefully, get my knee pain to a manageable (or nonexistent) level so that I can lead a normal life. I'm hopeful that, since I'm so young, that I will be able to live the rest of my life with my metal knee and do pretty much everything that my peers are doing. I would love to have the severe daily restrictions be a distant memory... I can't wait to climb the stairs whenever I need to, to make plans to go places without worrying that I'll be in too much pain to go, and to be able to exercise again. And one of the things I'm most excited about: actually being able to enjoy myself and not have to fake things! I've had to put on the "happy face" and do all sorts of things (ex. honeymoon excursions, charity walks, trips to amusement parks, etc.) when I've been in enough pain to take pretty much take away all my enjoyment. I guess I've done a good job though, maybe too good of a job... I've had a lot of peers at school say that they didn't know my knee was that bad because I just don't complain about it; I've had family members seem to underestimate my problems because I put on the "happy face" and don't bother talking about the pain (it just doesn't seem right to put it on everyone else).
But, as I mentioned, I'm also nervous... It seems to me that anyone going through a knee replacement should be nervous! A surgeon is about to slice open my whole knee, cut out a bunch of bone, and insert foreign objects. My advice: don't ever watch a video of a knee replacement or (God forbid) have shadowed a surgeon during the operation. Unfortunately, I've done both. While I feel well-educated, it makes things a bit scarier to have seen a bone saw in action and to see the pounding required to put in the replacement. But the thing that makes me the most nervous is the uncertainty. No one can give me stats on this surgery in someone my age. I could be facing a knee fusion or lower leg amputation at any point due to infection, a failed revision, or impossible revision. And, worst of all, I can't be sure what my level of pain will be after the surgery - it is expected that the pain will be greatly lessened but no one can make that guarantee and the worst thing I can think of (worse than amputation even) would be to have to continue to live at this level of pain or even greater pain for the rest of my life.
Well, we shall see! I will do my best to continue the updates... I have my pre-operative "class" tomorrow and my appointment with anesthesia (I did find out that an anesthesiologist that I know is available next Wednesday and I can request him for him surgery!) tomorrow morning. I'm excited to get my final questions answered... And then? It's back to my law school final exams! I have one final exam next Monday and one on Tuesday (then surgery on Wednesday); luckily I had an externship which is complete, a seminar which required writing a 30-page paper that is already turned in, and Advocacy which requires small assignments throughout the semester that are all finished. Until next time...
Tuesday, November 1, 2011
A bad few days...
I try not to complain about pain... I mean, when my husband asks or if someone sees me grimacing, I'll say that it's bothering me or it hurts, but I don't make a point to bother everyone with my complaints of pain. However, I'm sure that some people that might read these posts are in a similar situation and (figuratively and literally) feel my pain.
That said, these past few days have been terrible! It's been getting quite a bit colder and, in fact, Pennsylvania just got a dumping of snow over the weekend! Where I live, we got about 8 inches of snow on Saturday - actually a new record for our area (haven't had any snow in October since the mid-1970's and haven't had any real accumulation since that 1920's)! Well, as we all know, cold and damp makes our joints cramp... Unfortunately, the "cramp" is more of a persistent, severe pain. And to make matters worse, yesterday was a medical school/law school mock trial (basically we put on an abbreviated version of a medical malpractice trial where the residents play the doctors and experts and the lawyers formulate their theory of the case and conduct the direct and cross examinations). I was "volunteered" as a participant which required an awful lot of standing, walking, and (most unfortunately) climbing the stairs in the auditorium/courtroom.
So combining the additional movements and weight-bearing activity with the weather has made a very unhappy Nikki! And a very tired Nikki... since I haven't really been able to sleep since Friday night (and it's now Tuesday morning). Friday night was when the temperature really dropped and it was raining; Saturday came the additional precipitation with the snow. Sunday night wasn't too bad since I was down-right exhausted but I still probably only got about five "O.K." hours... And last night was the worst of all, combining the weather and activity. What I really don't understand is why I get so tired that I can fall asleep on the couch, watching TV or reading, at night but when I go to bed the pain then keeps me awake...
I can't wait until January or so when I've had my surgery and have gotten past the pain associated with the surgery... I'm going to hibernate for a few weeks! Well, sorry for the rant, but for anyone out there in my situation - I feel ya!
That said, these past few days have been terrible! It's been getting quite a bit colder and, in fact, Pennsylvania just got a dumping of snow over the weekend! Where I live, we got about 8 inches of snow on Saturday - actually a new record for our area (haven't had any snow in October since the mid-1970's and haven't had any real accumulation since that 1920's)! Well, as we all know, cold and damp makes our joints cramp... Unfortunately, the "cramp" is more of a persistent, severe pain. And to make matters worse, yesterday was a medical school/law school mock trial (basically we put on an abbreviated version of a medical malpractice trial where the residents play the doctors and experts and the lawyers formulate their theory of the case and conduct the direct and cross examinations). I was "volunteered" as a participant which required an awful lot of standing, walking, and (most unfortunately) climbing the stairs in the auditorium/courtroom.
So combining the additional movements and weight-bearing activity with the weather has made a very unhappy Nikki! And a very tired Nikki... since I haven't really been able to sleep since Friday night (and it's now Tuesday morning). Friday night was when the temperature really dropped and it was raining; Saturday came the additional precipitation with the snow. Sunday night wasn't too bad since I was down-right exhausted but I still probably only got about five "O.K." hours... And last night was the worst of all, combining the weather and activity. What I really don't understand is why I get so tired that I can fall asleep on the couch, watching TV or reading, at night but when I go to bed the pain then keeps me awake...
I can't wait until January or so when I've had my surgery and have gotten past the pain associated with the surgery... I'm going to hibernate for a few weeks! Well, sorry for the rant, but for anyone out there in my situation - I feel ya!
Sunday, October 23, 2011
Surgery is Scheduled!
Well, things are going well for me! It looks like I'm getting a good Christmas "present" this year. I met with the Dean at my law school who approved any exam rescheduling as long as the professor agreed. It took a little over a week to get my approvals, but everything is now a-go! I am taking both of my exams on the first two exam days (luckily, I only had two exams during finals week). This allows me to have the surgery on December 7th which gives me a full month before I need to return for spring semester on January 9th. I am a little worried about returning to school. Of course, I can't predict what my recovery will be like... But I keep reading that normally people should expect 6 weeks to 3 months off of work... and I'm looking at 4-5 weeks off of school! Ahhh! Well, another blessing: I only need 12 credits to graduate so I only need to take 4 classes as long as they are all 3 credits each. I even found a graduate level class that will count toward my degree that is online-only, so it looks like I'll only have to be on campus for just over six hours a day. Still stressful and, I have to say, I'm not looking forward to navigating the school after the surgery as it's not very handicap-accessible.
Anyway, back to the surgery, I also had to schedule an appointment with anesthesia and a "pre-op" class. I have read a lot about anesthesia options (general anesthesia, spinal, epidural, combinations, etc.). I'm not sure what will be recommended, but I've had an epidural in the past and suffered some complications, so I doubt that I will consider that as an option. We shall see what is suggested and I'll go from there! As for the "pre-op" class, I am a little leery that it will be focused on (sorry to be blunt) old people. I feel like my situation is so unique and unrelatable that a standard class won't be so useful to me... However, I did ask Dr. M about autologous blood donation (donating my own blood in case I need a transfusion during surgery) in an e-mail, but he said he doesn't recommend autologous transfusions but we'd discuss it in class. So at least I know a few things will be relevant!
So, things are set... I'm not really nervous yet - mainly I'm just excited! I'm a little worried as to how things will work regarding getting back to school and just getting along at home. My husband is great, but sometimes I think my limitations frustrate him. I'm a bit concerned my post-surgical limitations will be even worse. I'm planning to live with my parents for a period of time just after the surgery since my husband can't get any days off work and my mom doesn't work, so she'll be available to help. It will be interesting to see what my two dogs think - their "mommy" will be missing for a few days and then she will be stuck on the couch and they won't be allowed to jump on her!! This will be quite an experience... I'll try to keep this page updated as things move along!
Anyway, back to the surgery, I also had to schedule an appointment with anesthesia and a "pre-op" class. I have read a lot about anesthesia options (general anesthesia, spinal, epidural, combinations, etc.). I'm not sure what will be recommended, but I've had an epidural in the past and suffered some complications, so I doubt that I will consider that as an option. We shall see what is suggested and I'll go from there! As for the "pre-op" class, I am a little leery that it will be focused on (sorry to be blunt) old people. I feel like my situation is so unique and unrelatable that a standard class won't be so useful to me... However, I did ask Dr. M about autologous blood donation (donating my own blood in case I need a transfusion during surgery) in an e-mail, but he said he doesn't recommend autologous transfusions but we'd discuss it in class. So at least I know a few things will be relevant!
So, things are set... I'm not really nervous yet - mainly I'm just excited! I'm a little worried as to how things will work regarding getting back to school and just getting along at home. My husband is great, but sometimes I think my limitations frustrate him. I'm a bit concerned my post-surgical limitations will be even worse. I'm planning to live with my parents for a period of time just after the surgery since my husband can't get any days off work and my mom doesn't work, so she'll be available to help. It will be interesting to see what my two dogs think - their "mommy" will be missing for a few days and then she will be stuck on the couch and they won't be allowed to jump on her!! This will be quite an experience... I'll try to keep this page updated as things move along!
Monday, October 10, 2011
Decision-making...
Making the choice to have a surgery that could help you lead a relatively normal life is easy... Until you consider the risks... Until you consider the consequences...
Sure, I want the surgery so that I can climb stairs, exercise, concentrate in school or work, sleep at night, and get up off the floor without help. And I'm even willing to accept the possibility of an amputation. However, the uncertainty as to what risks I am going to encounter is a little frightening - I don't know how long the replacement will last, whether a difficult and painful revision will be required, whether I will have to battle infections, etc.
Worse, however, is the immediate consequences of the surgery. I know that I will have to stay in the hospital for several days, that I am facing months of difficult recovery, that I will have to go through painful physicial therapy, and that I will be dependent on family and friends for a period of time. At this point, I am at the end of my rope and I want this surgery, I need this surgery. I have decided to go through with it, but I need to figure out when will work. My conviction to have the surgery does not mean I am looking forward to the risks and consequences. I have endured painful physicial therapy before and I know what I'm in for. That alone is scary! But all I can do is hope that the risks and consequences will be worth it in the end.
In the end, my decision came down to the fact that almost all of the risks and all of the consequences would still be present in the future when I would have the operation. I do not believe I would make it much past 40 before I broke down and had to do the surgery and I'm not even sure how I would make it that far. Some days I just want to give up and some days I don't know how I keep moving... So, anyway, even if I made it to 40, I'd probably need a revision in my lifetime and I would be subject to the risk of injection. Moreover, the older I get, the higher the risk for the other "general" surgery risks. Plus, sad as this sounds, with my bum knee, I'm unable to exercise and therefore have difficulty managing my weight. If I had to weight until age 40, I'm sure my weight would be further out of control which lowers the success of the surgery and increases risk factors. I just don't see any benefit to waiting any longer...
I have come up with a pile of questions for Dr. M and will be emailing me to find out details about the procedure and what to expect. My next step is to meet with the Dean at the law school to try to reschedule my final exams - I have a winter break from mid-December to early-January and Dr. M believes if I have the surgery as soon as possible on my break that I can go back to school on-time with the same level of pain I currently am experiencing. However, I'm not certain how easy it will be to get the Dean and my professors to change the date and time of my exams. Hopefully they will be understanding! Wish me luck!
Sure, I want the surgery so that I can climb stairs, exercise, concentrate in school or work, sleep at night, and get up off the floor without help. And I'm even willing to accept the possibility of an amputation. However, the uncertainty as to what risks I am going to encounter is a little frightening - I don't know how long the replacement will last, whether a difficult and painful revision will be required, whether I will have to battle infections, etc.
Worse, however, is the immediate consequences of the surgery. I know that I will have to stay in the hospital for several days, that I am facing months of difficult recovery, that I will have to go through painful physicial therapy, and that I will be dependent on family and friends for a period of time. At this point, I am at the end of my rope and I want this surgery, I need this surgery. I have decided to go through with it, but I need to figure out when will work. My conviction to have the surgery does not mean I am looking forward to the risks and consequences. I have endured painful physicial therapy before and I know what I'm in for. That alone is scary! But all I can do is hope that the risks and consequences will be worth it in the end.
In the end, my decision came down to the fact that almost all of the risks and all of the consequences would still be present in the future when I would have the operation. I do not believe I would make it much past 40 before I broke down and had to do the surgery and I'm not even sure how I would make it that far. Some days I just want to give up and some days I don't know how I keep moving... So, anyway, even if I made it to 40, I'd probably need a revision in my lifetime and I would be subject to the risk of injection. Moreover, the older I get, the higher the risk for the other "general" surgery risks. Plus, sad as this sounds, with my bum knee, I'm unable to exercise and therefore have difficulty managing my weight. If I had to weight until age 40, I'm sure my weight would be further out of control which lowers the success of the surgery and increases risk factors. I just don't see any benefit to waiting any longer...
I have come up with a pile of questions for Dr. M and will be emailing me to find out details about the procedure and what to expect. My next step is to meet with the Dean at the law school to try to reschedule my final exams - I have a winter break from mid-December to early-January and Dr. M believes if I have the surgery as soon as possible on my break that I can go back to school on-time with the same level of pain I currently am experiencing. However, I'm not certain how easy it will be to get the Dean and my professors to change the date and time of my exams. Hopefully they will be understanding! Wish me luck!
Sunday, October 9, 2011
And finally some hope!
Everyone that talks to me about knee problems and my need for a knee replacement has a suggestion of "this doctor" or "that doctor" that I need to see, that would be my miracle doctor. So when a family friend suggested I see Dr. M, I wasn't expecting much. The friend did say Dr. M was known to help when no one else could. So I made an appointment...
The visit started off with the usual set of X-rays (standing, bent knee, and seated on the table with the knee bent about 90 degrees). I filled out all the usual paperwork - most of which had little to no application to me (When did you injure yourself?) or was just impossible to answer (What makes the pain worse? A: Everything; What makes the pain better? A: Nothing). And of course, the tiny box into which I am supposed to squeeze all my prior surgeries (I went for the "See Attached" approach).
Finally, the moment I was waiting for - Dr. M came into the exam room. I braced myself for the "Sorry but I can't do anything for you" and "Sorry but you're too young for a knee replacement" lines. They never came... Dr. M didn't treat me like a child, he didn't think I was there to get my hands on some narcotics, and he didn't think I just wanted someone to slice me open. He took me seriously. He saw how bad my knee was from the X-rays and he asked how my pain and problems interferred with my daily life. I'm not sure what came over me, but as I tried to tell him how I come down the stairs in my townhouse in the morning with everything I could possible need so that I don't have to climb the stairs until bed, the tears just started rolling down my face. I told him how the pain keeps me up at night or wakes me up in the middle of the night. I told him how the pain keeps me from concentrating at school or work. I told him how little I am able to exercise. And the tears kept coming... I'm not sure if the tears were because I needed to unload how much pain I was in or if it just was that tough to admit out loud what I kept bottled up. Either way, the tears didn't stop until I stopped talking about how terrible my life has become and how limited I am and how I just want to get around like a normal person again.
And then came the magic words - he is willing to do a total knee replacement on me as soon as I am ready. He told me what alternatives are available and he told me all the risks - but he also told me that he is confident that he can do this.
He told me the two alternative surgeries are an HTO (high tibial osteotomy) and a partial knee replacement. The HTO essentially means they cut the tibia bone and either take out a wedge of bone or insert a wedge of bone graft to change the angle of the tibia plateau; the purpose is to shift more of the weight bearing to the "good" side of the knee. In my case, my medial side (inner) is in worse shape than my lateral side (outer), so the bone would be cut and repositioned to shift the weight towards the lateral part of my knee. Most people are somewhat familiar with partial knee replacements (also called a unicompartmental knee replacement); in this surgery, only the medial or the lateral side of the joint is fitted with the metal and plastic parts. Again, since my medial side is worse, the lateral side would be left alone and the medial side would be replaced. However, Dr. M told me that neither is a good option for me because, while the lateral side is in better shape than the medial side, the lateral side is still significantly damaged. In addition, I had already tried a deloading brace which does approximately what the HTO procedure does and Dr. M said the HTO surgery makes a later knee replacement much more difficult.
Now, on to the risks... Of course, there are the general risks anyone undergoing surgery faces such as blood clots, heart attacks, strokes, etc. Specific to the knee replacement (and similiar to risks of other joint replacement), there is concern the implanted joint becomes dislodged or loose over time or that the implanted joint wears out. Of course, these risks are greater for younger patients - we are more activity and will be expected a longer life out of the joint. In my case, being only 26, it is pretty much assured that the joint will need to be replaced again in my lifetime. Another risk is infection; unlike regular surgeries where infection is a concern immediately but only until the surgical site is healed, with joint replacements, the concern can be lifelong. Any time bacteria gets into the bloodstream, there is the chance that it can make its way to the joint and it will colonize and grow on the metal and plastic. For this reason, patients need to take antibiotics before any dental procedures or similiar procedures where bacteria could be introduced into the bloodstream. At this point, I'm not sure whether I would have to do that forever, as some sources say, or whether it would be for a shorter term such as five years, as others sources state. In either regard, this is a serious risk. If the infection of the joint occurs, the doctor may be able to clean out the joint or they may have to take out the implanted joint. If the latter occurs, the doctor may be able to do a revision (essentially do a new replacement) or may have to go to the "optionss of last resort" (which I will explain in a moment).
The scariest risk is that, in the future, the replacement will fail and a revision will be impossible. Revisions are more difficult than the original replacement and are not always possible. In that case (as well as in the case of an infection which cannot be treated), there are only two options - what I have termed the "options of last resort": knee fusion or amputation above the knee. The knee fusion will result in the inability to bend the knee which will make walking awkward but will still enable the patient to lift leavy objects and be mobile. The amputation may be better for someone behind a desk, where a permanently stick-straight leg may be problematic). Dr. M told me that if I'm not ready to face the options of last resort, I am not ready for the replacement. However, for me, this is not a large concern. While the thought of only having half of a left leg is odd and not particularly pleasant, I asked Dr. H years ago whether he would simply amputate above the knee joint and let me live a mostly-normal life with a prosthetic. (I simply feel that many amputees have a better quality of life than I do.) And, being a law student, I intend to spend most of my life behind a desk, so a knee fusion, while it would allow me to look more like an average person (until I start walking), it would make office life difficult.
Dr. M was willing to schedule the surgery right away, but he also encouraged me to seek any second opinions I needed, to take the time to talk it over with anyone, and to ask him any questions I might have. He gave me his email address so that I can communicate with him whenever is best for me - he said he would answer any of my questions and could even schedule my surgery through email. And, before I left, he gave me a cortisone shot, though he doubted it would do much, just so I wouldn't question whether such shots could buy me some time and so I didn't feel as though I got nothing out of my visit. (FYI: It's two days later - the numbing medicine in the shot felt great for an hour, then I spend the next 12 hours with a super-stiff, painful knee, and then was back to my normal pain level. Conclusion: cortisone shots are worthless to me at this point.)
Dr. M has given me plenty to think about and discuss, but most importantly, he has given me some hope. My family and I are so grateful that he is willing to do what no one else is and that he comes so highly recommended.
The visit started off with the usual set of X-rays (standing, bent knee, and seated on the table with the knee bent about 90 degrees). I filled out all the usual paperwork - most of which had little to no application to me (When did you injure yourself?) or was just impossible to answer (What makes the pain worse? A: Everything; What makes the pain better? A: Nothing). And of course, the tiny box into which I am supposed to squeeze all my prior surgeries (I went for the "See Attached" approach).
Finally, the moment I was waiting for - Dr. M came into the exam room. I braced myself for the "Sorry but I can't do anything for you" and "Sorry but you're too young for a knee replacement" lines. They never came... Dr. M didn't treat me like a child, he didn't think I was there to get my hands on some narcotics, and he didn't think I just wanted someone to slice me open. He took me seriously. He saw how bad my knee was from the X-rays and he asked how my pain and problems interferred with my daily life. I'm not sure what came over me, but as I tried to tell him how I come down the stairs in my townhouse in the morning with everything I could possible need so that I don't have to climb the stairs until bed, the tears just started rolling down my face. I told him how the pain keeps me up at night or wakes me up in the middle of the night. I told him how the pain keeps me from concentrating at school or work. I told him how little I am able to exercise. And the tears kept coming... I'm not sure if the tears were because I needed to unload how much pain I was in or if it just was that tough to admit out loud what I kept bottled up. Either way, the tears didn't stop until I stopped talking about how terrible my life has become and how limited I am and how I just want to get around like a normal person again.
And then came the magic words - he is willing to do a total knee replacement on me as soon as I am ready. He told me what alternatives are available and he told me all the risks - but he also told me that he is confident that he can do this.
He told me the two alternative surgeries are an HTO (high tibial osteotomy) and a partial knee replacement. The HTO essentially means they cut the tibia bone and either take out a wedge of bone or insert a wedge of bone graft to change the angle of the tibia plateau; the purpose is to shift more of the weight bearing to the "good" side of the knee. In my case, my medial side (inner) is in worse shape than my lateral side (outer), so the bone would be cut and repositioned to shift the weight towards the lateral part of my knee. Most people are somewhat familiar with partial knee replacements (also called a unicompartmental knee replacement); in this surgery, only the medial or the lateral side of the joint is fitted with the metal and plastic parts. Again, since my medial side is worse, the lateral side would be left alone and the medial side would be replaced. However, Dr. M told me that neither is a good option for me because, while the lateral side is in better shape than the medial side, the lateral side is still significantly damaged. In addition, I had already tried a deloading brace which does approximately what the HTO procedure does and Dr. M said the HTO surgery makes a later knee replacement much more difficult.
Now, on to the risks... Of course, there are the general risks anyone undergoing surgery faces such as blood clots, heart attacks, strokes, etc. Specific to the knee replacement (and similiar to risks of other joint replacement), there is concern the implanted joint becomes dislodged or loose over time or that the implanted joint wears out. Of course, these risks are greater for younger patients - we are more activity and will be expected a longer life out of the joint. In my case, being only 26, it is pretty much assured that the joint will need to be replaced again in my lifetime. Another risk is infection; unlike regular surgeries where infection is a concern immediately but only until the surgical site is healed, with joint replacements, the concern can be lifelong. Any time bacteria gets into the bloodstream, there is the chance that it can make its way to the joint and it will colonize and grow on the metal and plastic. For this reason, patients need to take antibiotics before any dental procedures or similiar procedures where bacteria could be introduced into the bloodstream. At this point, I'm not sure whether I would have to do that forever, as some sources say, or whether it would be for a shorter term such as five years, as others sources state. In either regard, this is a serious risk. If the infection of the joint occurs, the doctor may be able to clean out the joint or they may have to take out the implanted joint. If the latter occurs, the doctor may be able to do a revision (essentially do a new replacement) or may have to go to the "optionss of last resort" (which I will explain in a moment).
The scariest risk is that, in the future, the replacement will fail and a revision will be impossible. Revisions are more difficult than the original replacement and are not always possible. In that case (as well as in the case of an infection which cannot be treated), there are only two options - what I have termed the "options of last resort": knee fusion or amputation above the knee. The knee fusion will result in the inability to bend the knee which will make walking awkward but will still enable the patient to lift leavy objects and be mobile. The amputation may be better for someone behind a desk, where a permanently stick-straight leg may be problematic). Dr. M told me that if I'm not ready to face the options of last resort, I am not ready for the replacement. However, for me, this is not a large concern. While the thought of only having half of a left leg is odd and not particularly pleasant, I asked Dr. H years ago whether he would simply amputate above the knee joint and let me live a mostly-normal life with a prosthetic. (I simply feel that many amputees have a better quality of life than I do.) And, being a law student, I intend to spend most of my life behind a desk, so a knee fusion, while it would allow me to look more like an average person (until I start walking), it would make office life difficult.
Dr. M was willing to schedule the surgery right away, but he also encouraged me to seek any second opinions I needed, to take the time to talk it over with anyone, and to ask him any questions I might have. He gave me his email address so that I can communicate with him whenever is best for me - he said he would answer any of my questions and could even schedule my surgery through email. And, before I left, he gave me a cortisone shot, though he doubted it would do much, just so I wouldn't question whether such shots could buy me some time and so I didn't feel as though I got nothing out of my visit. (FYI: It's two days later - the numbing medicine in the shot felt great for an hour, then I spend the next 12 hours with a super-stiff, painful knee, and then was back to my normal pain level. Conclusion: cortisone shots are worthless to me at this point.)
Dr. M has given me plenty to think about and discuss, but most importantly, he has given me some hope. My family and I are so grateful that he is willing to do what no one else is and that he comes so highly recommended.
Friday, October 7, 2011
A (not-so) brief history...
All of my knee problems started when I decided it was a good idea for a thirteen year old girl to play on a boys' soccer team. An angry opponent esstentially tackled me while all of my weight was on my left knee and I was rotating to kick the ball with my right leg. I tore my ACL and tore my meniscus - not that the doctors figured that out right away (my physical therapist was the one who pretty much diagnosed me), but that's a story for another time.
After an ACL reconstruction (August 1999) and many months of physical therapy, I was finally able to return to playing soccer after a year off. At that point, I was in 9th grade. I made the varsity soccer team and had a good year that was uneventful in terms of my knee. Unfortunately, my 9th grade year was my only "good" year for my knee. After that point, I would play the spring girls' soccer season and follow it up with an arthroscopic knee surgery. Shortly after graduating high school, I had my fourth knee surgery before heading off to college (June 2004). The surgeries generally consisted of cleaning up articular cartilage (the cartilage layer on the femur bone) that was falling off, mending tears of my menisci, and tightening up my ACL graft.
At this point, I had seen two different surgeons. The first was Dr. F at OIP - he did my ACL reconstruction. When I started having problems again, I went to see Dr. H at AO - he came highly recommended. I loved Dr. H; he was very understanding, knowledgeable, and personable. He did everything he could to accomodate my schedule and my needs. He really cared about my progress and wanted to "fix" me. However, at the this point, Dr. H felt there was little more he could do for me - we had tried several arthoscopic procedures, Synvisc, Euflexa, and steroid shots. Dr. H wanted me to get a second opinion and suggested I see Dr. F (a different one!) at RI. Dr. H had given me three options at that point: 1) an abrasion chondroplasty (explained below), 2) a bone plug procedure (OATS procedure, using cadaver plugs), or 3) an autologous chondrocyte implantation or ACI (growing my own cartilage in a lab and implanting it). Dr. H could do the first or second options but wanted me to see Dr. F at RI about the third option. In short, Dr. F at RI saw me, did an exploratory arthroscopy (cleaned up a bit while he was in there), and determined I had too much damage for either the OATS procedure or the ACI.
At this point, I schedule my third surgery in under 12 months. We decided to do the abrasion chondroplasty with Dr. H in spring 2005. This surgery essentially consists of using a burr to "rough up" the bone surface and drilling small holes to produce bleeding; the procedure intends to produce a layer of scar tissue to serve as a substitute for the missing cartilage. The surgery was ineffective and I was out of options. We continued using Euflexa (I had developed an allergy to Synvisc from prolonged use) and steroids with little relief.
Then a terrible thing happened - Dr. H was going to retire! We had discussed knee replacement and he said he expected to do it before I was 40; slowly over time, the goal was changed to making it to age 30. Now, he was retiring and so were my hopes of a timely knee replacement. Before he left the practice at AO, he did a final arthroscopy on me (July 2009) to clean things up and hopefully buy me some more time.
In fall 2010, I went to another surgeon at AO, Dr. K, to discuss my options as my pain was increasing daily. He was less than helpful and essentially told me that he would not do a knee replacement before I was 40 and even at that point, he would tell me to wait longer, regardless of whether I was in chronic pain and stuck in a wheelchair. It was at that point that I began to doubt I'd ever find someone to help me...
After an ACL reconstruction (August 1999) and many months of physical therapy, I was finally able to return to playing soccer after a year off. At that point, I was in 9th grade. I made the varsity soccer team and had a good year that was uneventful in terms of my knee. Unfortunately, my 9th grade year was my only "good" year for my knee. After that point, I would play the spring girls' soccer season and follow it up with an arthroscopic knee surgery. Shortly after graduating high school, I had my fourth knee surgery before heading off to college (June 2004). The surgeries generally consisted of cleaning up articular cartilage (the cartilage layer on the femur bone) that was falling off, mending tears of my menisci, and tightening up my ACL graft.
At this point, I had seen two different surgeons. The first was Dr. F at OIP - he did my ACL reconstruction. When I started having problems again, I went to see Dr. H at AO - he came highly recommended. I loved Dr. H; he was very understanding, knowledgeable, and personable. He did everything he could to accomodate my schedule and my needs. He really cared about my progress and wanted to "fix" me. However, at the this point, Dr. H felt there was little more he could do for me - we had tried several arthoscopic procedures, Synvisc, Euflexa, and steroid shots. Dr. H wanted me to get a second opinion and suggested I see Dr. F (a different one!) at RI. Dr. H had given me three options at that point: 1) an abrasion chondroplasty (explained below), 2) a bone plug procedure (OATS procedure, using cadaver plugs), or 3) an autologous chondrocyte implantation or ACI (growing my own cartilage in a lab and implanting it). Dr. H could do the first or second options but wanted me to see Dr. F at RI about the third option. In short, Dr. F at RI saw me, did an exploratory arthroscopy (cleaned up a bit while he was in there), and determined I had too much damage for either the OATS procedure or the ACI.
At this point, I schedule my third surgery in under 12 months. We decided to do the abrasion chondroplasty with Dr. H in spring 2005. This surgery essentially consists of using a burr to "rough up" the bone surface and drilling small holes to produce bleeding; the procedure intends to produce a layer of scar tissue to serve as a substitute for the missing cartilage. The surgery was ineffective and I was out of options. We continued using Euflexa (I had developed an allergy to Synvisc from prolonged use) and steroids with little relief.
Then a terrible thing happened - Dr. H was going to retire! We had discussed knee replacement and he said he expected to do it before I was 40; slowly over time, the goal was changed to making it to age 30. Now, he was retiring and so were my hopes of a timely knee replacement. Before he left the practice at AO, he did a final arthroscopy on me (July 2009) to clean things up and hopefully buy me some more time.
In fall 2010, I went to another surgeon at AO, Dr. K, to discuss my options as my pain was increasing daily. He was less than helpful and essentially told me that he would not do a knee replacement before I was 40 and even at that point, he would tell me to wait longer, regardless of whether I was in chronic pain and stuck in a wheelchair. It was at that point that I began to doubt I'd ever find someone to help me...
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