Wednesday, September 29, 2004

Knee-day: in the hospital room

Knee-day: Wednesday, 29-Sep-2004:
In the hospital room:
I remember moving in the hallways on the cart; rolling (with assistance) from the gurney to the bed; getting everything hooked up, from the puls-ox monitor to the inflatable boots over my lower legs. A nurse gave me instructions on “the button” for pain control. My wife was there with me, and she had the bag of clothes from the gurney in her hand. She put it in the room’s closet.

I got to the hospital room about noon. Surgery was scheduled to take 45 minutes. It actually took two hours, thanks to the amount of gravel in the knee, and the need to remove the synovial membrane. There was ice water available --- I was certainly thirsty.

The blood draws seemed to start immediately. There were BP checks almost hourly (or so it seemed).

About 4 PM, a nurse came in to see if I could go to physical therapy (PT). I sat up OK, but when I attempted to stand, I got very light-headed, sat down (and backwards) very quickly and blacked out for a few seconds. My BP was not stable due to low blood volume, and I became hypotensive when I tried to stand. I was told to drink fluids, to build my blood volume back up. “You’ll go to PT tomorrow ...”

I was still dressed in a hospital gown that was open in the back, but was allowed to pull on short-ee pajama bottoms if I chose. I used knee length boxer shorts, made from soft jersey. Very baggy, which enabled me to thread the catheter bags under them for convenience.

Apparently, I was losing a lot of blood into the drain. Total blood loss during surgery was only ca. 100 mL (a tourniquet was used around the thigh above the knee), but I lost an additional 2 L or so of blood in the first 24 hrs post-surgery. [Yes, 2 L. This is a considerable loss of the body's blood volume]. There was a lot of hand-wringing by the nurses over the amount of blood going into the drain. I also ripped the end of the drain out of the bag a couple of times as I learned to move around with the catheters. This was better than ripping it out of my leg, I guess, but I made quite a mess.

A nurse came in and taught me to do breathing exercises using a plastic respirometer device. One size fits all. Inhale 2500 mL over 10 sec (move the little yellow ball up the tube), then exhale. Repeat 10X. This was a very effective device for deep breathing. For me, one deep breath raised the blood O2 concentration (measured via the fingertip puls-ox monitor) by about 1%.

The same nurse me some in-bed exercises that I was supposed to do once an hour or so. Simple and standard leg/knee stretching and flexing exercises. Quad sets. Ankle pumps (keep that venous blood moving). I was also allowed to do straight leg raises (when the compression stockings were off), but little else. This was a surprise. I was prepared for a lot more in-bed exercises.

There are two doctors in the family practice which we use. The partner who is not our family physician stopped to see me, which was a surprise. Apparently, the surgeon’s office routinely notifies the family physician when there is a surgery, so the partner stopped during his hospital rounds (my family doc was not at the hospital on Wednesday). He was not happy with the blood loss nor with my low BP. He cranked up the IV flow substantially to increase my fluid volume. He asked me to drink more by mouth. He was also not happy with my blood counts, so he added an iron (Fe) supplement to the routine.

Dinner came. No problems with eating/drinking, but I continued to push fluids.

My wife stayed until relatively late, simply holding my hand as I drifted in and out of alertness. Popsicles were available for me, too, whenever I wanted them.

The hospital shifts ran 7 to 3, 3 to 11, 11 to 7. At the change of each shift, someone would come in and check BP and temp; draw blood (clotting time, probably); check the urine and blood drains. IV bags were also checked routinely, but they also had their own volume alarms attached.

Post-op antibiotic therapy used some cephalosporin derivative; administered via the IV bag post-op, as two roughly 8-hr doses. Surprising to me, there was no additional antibiotic administered subsequently by mouth. And, interestingly enough, a swollen gland under my jaw (swollen since a root canal a few years ago) disappeared at the same time. I assume that the gland had a sub-clinical chronic infection, and that the high dose post-TKR surgery knocked that one out, too. [This later proved to be the WRONG assumption].

Antibiotic prophylaxis actually began during surgery. Irrigation of the site occurred throughout the surgery, using sterile water and a strong antibiotic. The surgeon described the process as a big Waterpik spraying away where they were working.

I began oral warfarin at 4 PM on knee-day. I assumed that an anti-coagulant therapy was also used during surgery, but have no verification of that.

The epidural catheter and Foley catheter remained in place, as did the wound drain. Fentanyl was available through the epidural, 3 doses per hour available through the button. I could feel the coolness of the ambient temperature fluid move through the epidural catheter as it crossed my shoulder and traveled under an adhesive pad (about 9 x 12”, apparently covering the entirety of my back from shoulder to lumbar region). By the time the cool fluid bolus got from my shoulder to the middle of my back, it had warmed to body temperature, and I could no longer feel it, nor could I feel it as it entered the epidural space. Time from pushing the button to being able to notice the effect (pain relief) was only a few minutes, and for the first few days post-surgery, this was much needed.

Hospitals at night are noisy. I brought along a cheap battery-powered radio with decent stereo headphones, and found this to be a sanity-saver during the nights. The room TV had a audio jack that also fit my headphones, so I could watch CNN all night long, if I wanted. Or, I could listen to the radio, and blank out the hallway noise very effectively.

Note re inflatable boots:

These are pneumatic compress-and-release cuffs that cover from ankle to knee, both legs. These provide good immobilization as well as prevent embolisms. However, they are plastic, and for me were annoyingly hot and sweaty, even with the TED stocking in between. Also, please be aware that if these are not properly placed on your leg, the compression will hurt a lot. There should be no additional pain when these are properly inflated. [I found this out when I removed them on my own to go to the bathroom, and put them on improperly by myself when I got back to the bed ...]

Note re puls-ox monitors:
These have controllable alarms. When I fell asleep, my blood O2 tended to fall just under the alarm trigger. So I would fall asleep; the alarm would go off and wake me up; I’d take a couple of deep breathes; the alarm would shut off, etc. This went on all night long. Finally, one of the night shift nurses said “Let’s just turn the volume down so you can sleep.” Bliss. You should realize that the alarm is connected to a monitoring station at the nurse’s desk, regardless of whether the volume on the local alarm is on.