Progress Report, Smoke Report, Surgical Error Report, Kasha Report

Three weeks post knee replacement, I've gone from using a walker, to two crutches, to one crutch, to a trekking pole (an adjustable walking stick with a strap), to no aid at all around the house. Instead of working out three times a day for twenty minutes, I work-out almost continually throughout the day (as I write this, I'm flexing and straightening my knee. My major goals for the first six weeks are achieving a normal bend in the knee (120-degrees) and being able to completely straighten the knee. Last Friday, my bend was 105, which was good, and I was three degrees from achieving complete straightness.

Yesterday was house-cleaning day, and I excitedly anticipated being able to help, but after two and half hours on my feet, the knee started to swell (more than it is normally swollen), turn red, and feel hot. The PT said that I could expect swelling to be a problem for two or three months, and, of course, it negatively impacts my therapy goals. There's nothing I can do for it but to lie around for hours everyday with my knee elevated above my heart, and ice packs draped over my knee. It's enough to drive a person crazy. At this point ALWAYS feels like the stiffest knee that a normal person ever had in his life, and it NEVER stops hurting, but it's not pain that's through the roof. One good thing I can say about the pain of exercising is that it was many times worse when I started than it is today, and that by itself is enough to keep me motivated to work-out. 

Until a few days ago, the only outdoor walking I did was to and from the car for my physical therapy appointments. This was because the smoke from the many forest fires (I live in Oregon's Willamette Valley) has been so bad that people are advised to stay indoors. Fortunately, Peggy and I have air conditioning, something that not everyone here has because really hot days are rare--or at least they used to be. 

The smoke has been SO bad of late that there have been days when the sun never appeared; we couldn't see the nearby hills; and we could even see smoke by looking toward the shrubbery in the backyard looked smoky. Peggy taped cardboard over our bathroom vent fan; laid towels along the bottoms of doors to the outside; and avoided opening outside doors if she could help it. Picture a bad air day in Beijing, and that's what much of Oregon looks like. Peggy has had bronchitis and an ear infection from the foul air (she was prescribed steroids and is much improved), and many people are wearing masks. We get some smoke from forest fires almost every year, but this is record-breaking, and it has been going on for over two weeks. Fortunately, it has gotten some better during the last few days due to a front moving through. We even had our first rain in months, although it only lasted a few minutes. Every summer here is a drought summer, but as with the heat, the droughts are getting worst.

Once all the steri-strips fell off so that my incision was visible, my physical therapist (Kasha) pointed out that the incision was crooked (she thought this was a lot funnier than I did), and indeed it looked like what you would expect if a drunk man with palsy tried to draw a straight line seven inches long. I knew that Brian didn't have palsy, and after much reflection, I eliminated as untenable the possibility that a sex kitten of a nurse might have goosed him during surgery, and this left me with but one inescapable conclusion, namely that Brian had operated on me at 7:00 in the morning while drunker than a skunk, and that he had put my new joint in upside down and backwards. I knew this had to be the case because if the situation were otherwise, he wouldn't have been chewing gum to mask the alcohol odor, and I would be able to straighten the knee completely. Also, when I bend it, it would bend in the back like a normal knee instead of in the front like a bird's knee. I think that the best option at this point is for Brian to replace the right knee too, and to put it in upside down and backwards, so that it will match the left knee. Naturally, I would expect him to do this for free. It's a sucky situation, but I'm sure it happens all the time, and I don't hold it against him. Actually, it reminds me of a funny story.

If you've had surgery at either of the local hospitals in the last thirty years or so, you know that the surgeon will come around and put a mark on the spot where he or she is going to operate. He will do this while you're still awake, and you're expected to verify that he's marking the correct place, the goal being to avoid the embarrassment that comes when doctors operate on the wrong patient, amputate the wrong leg, perform hysterectomies on ninety year old men, do tummy-tucks on four year olds, and other fox paws (fox paw is French for fuck-up). As many of you know, Peggy spent her last 24 years as a nurse in an OB unit that was devoted exclusively to labor and delivery patients. Word came down one day that all of the doctors would be forevermore expected to mark the abdomens of all of their C-section patients in order to insure that they (the doctors) wouldn't do something embarrassing like removing a woman's ring fingers. The doctors considered the new rule too stupid for words, and the nurses backed them, so it was soon discarded.

But back to Kasha. I liked her quite well when we met, but she's an avid cyclist, and when the smoke became bad enough that biking was making her throat hurt, she became so despondent that I started to dread seeing her. She would bitch about the smoke; about not having air conditioning at home; about her gym being closed for servicing just when she needed it most; about her difficulty with getting a baby sitter; and about injuries from old bike wrecks; but especially about being unable to ride her bike. I was one appointment away from either having a serious talk with her or simply going to another therapist when she immediately turned herself around and became as good a therapist as I had thought she was when we first met. I even told her after my last session that I had enjoyed working with her, which surely isn't something she hears much from knee replacement patients because these sessions are painful. She looked like she could have cried, and I went away feeling very glad that I hadn't fired her before she could pull herself together.

Come and Gone

Sacred Heart Hospital

"O, the joy! Oh yeah, uh!" Explorer William Clark upon reaching Oregon's Pacific shore in 1805.

We got up at 3:30 on Thursday morning for the 7:30 surgery. The anesthesiologist and the surgeon, Brian, visited me as I lay in bed in the holding area. The anesthesiologist was mellow; Brian, intense as ever, was chewing his gum violently. If he hadn't come well-recommended, I would have suspected that whatever brains he was born with had been displaced by testosterone. I said that it was time for him to work his magic, and he gave me the best reassurance imaginable, "This isn't magic; it's carpentry.

I received my spinal in the OR where doctors have replaced their masks with what look like helmets. I could hear the saw and smell the stench as Brian cut through my bones. Then came the hammering of metal, and I remembered his carpentry allusion. 

The recovery room nurse said that the hospital regularly books more people into surgery than it has places to put them, but that if I were lucky, a room might open up later in the day. If I wasn't lucky, I would have to hope for a better tomorrow.

Three and a half hours later, a room opened up. The labor and delivery rooms (where Peggy used to work) are spacious and have good views of the McKenzie River and the Coburg Hills, so I expected the orthopedic floor to be the same. It was not. My room was so small (not to mention dingy) that workers were forever having to move some things around to get to other things. An outside wall blocked any view lower than the tops of the nearby Coburg Hills.

The pain was intense, and Brian had gone on vacation without following through on his promise of extra narcotics. When I colored the air with expressions of indignation, the powers that be decided to give me 30 mgs of oxycodone at once each morning and an additional 10 mgs every three hours round the clock. A pharmacist dropped by and said I was at risk of respiratory arrest from what she considered an ungodly amount of narcotics. I assured her that she was wrong, and she went away sulking. That night, a 10 mg Ambien, a 45 mg Remeron, a 5 mg Flexeril, and various other drugs were added to the oxycodone, and I became so shit-faced that I didn't know I was in the hospital.

A few hours after surgery, a physical therapist had me walking (with a walker) and doing flexibility exercises. The next day, I attended my first joint rehabilitation class (two of them a day), and walked the loop that circled around the orthopedic floor (there was even a board on which to advance your magnet every time you completed a loop). While in bed, one machine circulated cold water around the surgical site, another machine massaged both legs in the direction of my heart, and the bed itself had a barely noticeable massage function that increased circulation and prevented bed sores. 

The day after surgery, my temperature hit 38.2 C (100.7 F),  my knee swelled to half again its normal size, and I wasn't getting nearly enough laxative to allay the narcotic-induced constipation. When I said that I hadn't pooped since the day before the surgery, I was given a dose of ExLax. When that didn't work, I opted for a suppository, but the result was more worthy of a housecat than a man. By the next day (two days after surgery), my temperature was normal, but I felt like I had a five pound weight on my chest. I hated to mention it to the Nurse Bridget, because I didn't want pandemonium to develop over something that I really didn't think was a problem. Prudence won the day, and Bridget immediately called her supervisor. When Bridget told her that my color was good, that the pain didn't radiate, and that it felt more like pressure than actual pain; she was told not to worry. An hour later, I felt fine and said I wanted to go home. My total time in the hospital had been 56 hours.

The first thing did when I got home was to exchange greetings with three mystified cats. The second was take a couple of sodium docusates, drink a lot of water, and eat a lot of prunes. A few hours later, I had that long awaited bowel movement, but it didn't amount to much, which was just as well because lowering myself onto the pot took so long that I ended up pooping from a standing position. This very scenario had been a concern of mine at the hospital where I told Nurse Bridget that I'm a refined person, and that refined people rarely take dumps on the floor. 

My embarrassment brought to mind an experience Peggy had when she was a new nurse with a dying patient who was having bout after bout of diarrhea, each of which hit him so fast that he was unable to wait for a bedpan. His last words were repeated apologies to Peggy, and she has never stopped regretting that she was unable to find words that would have enabled that man to die in peace. If she had said what she was thinking, she would have told him that it was an honor to attend to the needs of a man for whom she felt such affection and respect. She couldn't say this because she had only met him that day and because it would have represented a greater act of intimacy than her need for professionalism would have allowed. I can but say that the workers who served me best while I was in the hospital were the ones who seemed vulnerable.

Compared to the pain that I live with and the pain that followed my three shoulder surgeries, the pain from this surgery just isn't that bad. I was told to expect hell, but my primary feeling is joy as I prepare to get on with my life minus one source of pain. My ignorance of how little pain normal people experience had at times caused me to suspect that I was simply a woos, but now that my vision has cleared, I say to you that I really do suffer. To the knee replacement fear-mongers in particular, I would scream, "What! You call this pain?" While I suppose it's possible that I'm so stupid that it takes days for pain in my knee to register in my brain, I am nonetheless optimistic.

Today is Monday, so I'm only four days post-op, yet every time I do my exercises, I see improvement. I just hope I can resist my desire to push myself too hard too fast. Brian said it would be six weeks before I could mow the lawn, but while I was out the backyard just now watching the solar eclipse, I thought to myself, "Hell, I could mow today."

The Day and the Hour Rapidly Approach

Men Sleeping in the Rain, Green Park, London, 1902

"It was a welter of rags and filth, of all manner of loathsome skin diseases, open sores, bruises, grossness, indecency, leering monstrosities, and bestial faces. A chill raw wind was blowing, and these creatures huddled there in their rags, sleeping for the most part, or trying to sleep....It was this sleeping that puzzled me. Why were nine out of ten of them trying to sleep? But it was not till afterward that I learned. It is a law of the powers that be that the homeless shall not sleep by night." (Jack London, from The People of the Abyss)
 
I've had one other joint replacement--my left shoulder--and am astounded by how different the required preparation has become. I got ready for that 2011 operation by going to a surgeon who looked at my x-rays and gave me a date for the procedure. A week prior to that date, I underwent blood tests, a brief visit with an anesthesiologist, and maybe an EKG. Here's what I have to do this time around:

In June, I had my first visit with a surgeon who looked at my x-rays and proposed a total knee replacement. A few weeks later, I spent an hour with my assigned "care coordinator." Ten days after that, Peggy and I attended a required two-hour joint replacement class. This Monday, I spent a combined ninety minutes with a medical assistant, a phlebotomist, an EKG technician, and an anesthesiologist. Today, I have a preparatory visit with the surgeon. So there you have it--many things to do, many people to see, many assigned exercises that I'm in too much pain to do, and a large binder of reading materials. I feel more unnerved than informed by all of this because it makes the surgery seem like a big deal, which it is, of course, but I could do with a few less reminders.

Before I had my first shoulder surgery, I made the mistake of watching the procedure on the Internet, and what I learned was that I have NO desire to ever again watch a surgery for which imagination alone will suffice. You might wonder why I am SO scared, and I've asked myself that same question. Aside from the risk of stroke, infection, weeks of pain and disability, and the failure of the new joint to bring relief, the thing that bothers me most is that I feel like a genetic weakling because so many parts of my body hurt so much, and because only one of the bone-related surgeries I've had (carpel tunnel) brought me significant relief. After this knee replacement, I'll be having elbow surgery, and then there's the likelihood of more shoulder surgeries. Even if I am so fortunate that these things help, I'll still live with significant back pain, and I'll still live in fear that my narcotics will be taken away. Ergo, I have no hope that I will ever be without pain and disability, and the fact that I'm about to do something that, for a couple of months, will add to that pain, makes me tremble.

On the bright side, I recognize that there is cause for hope based upon the skill of my surgeon and the advanced state of knee replacements. I tell myself that this surgery is just one more thing of many things that I have endured, or will endure, and that my life is a bowl of cherries compared to the lives of millions of creatures.

I'm a lover of Jack London, who made a career of writing about--and photographing--human misery, and who himself endured great pain toward the end of his forty-year life. I read him now partly because I need perspective, and I get it from reminding myself of the many millions of people who were--and are--far worse off than I due to the fact that they had no money, no safety, no shelter, no healthcare, little food, no loved ones, and no cause for hope. Compared to the misery of the humans and other creatures with whom London came in contact during his travels around the world, my problems are minor:

"From the slimy, spittle-drenched sidewalk, they were picking up bits of orange peel, apple skins, and grape stems, and they were eating them... They picked up stray crumbs of bread the size of peas, apple cores so black and dirty one would not take them to be apple cores, and these things the two men took into their mouths and chewed them, and this between six and seven o'clock in the evening of August 20, the year of our Lord 1902, in the heart of the greatest, wealthiest, and most powerful empire of the world." (op. cit.)