Thursday, September 30, 2004

Good coffee makes all the difference in the world

Knee-plus-one: Thursday, 30-Sep-2004:
I woke up with the 7 AM change in shift. My wife stopped in on her way to work, bringing me a go-cup with REAL coffee. Ahhh. We’ve been drinking fresh ground coffee for years, thanks to our children who bought us a grinder for Christmas once upon a time.

Pain control during the first night was fine. It was much much better control than I had following the meniscectomies in 1969 and 1973. In the pre-arthoscopy days, pain control was by nerve block, and when the block wore off post-surgery, the only pain control was by narcotic injection (demerol, in my case). PCA (“the button”) is a much, much better way to go.

Breakfast arrived relatively late for my normal schedule --- I was ravenous --- and most of the shift change actions had already occurred by the time breakfast came.

After breakfast, I was allowed to walk into the bathroom using a walker, and to sponge-bathe in private. Of course, I was accompanied by my IV tree, to which was attached my Foley bag. Of course, the nurse stayed within ear shot of the room. We clipped the blood drain bag to my boxer short-pajamas. The puls-ox monitor was disconnected during bath time, and reconnected when I got back to the bed.

I have kept my hair in a crewcut for years, and having a crewcut made a sponge bath very effective. It felt especially good after a relatively warm night, wearing TED stockings and plastic inflatable legs. Bathe. Brush teeth. Put on fresh clothes. Ahhh.

PT began at 10 AM, but only after the nurses were sure that my BP was stable upon sitting and standing. No light-headedness this AM. I went to PT in a wheelchair, wearing a robe over the hospital gown and shorts. Mostly, in-hospital PT consisted of assisted walking (get out of the wheelchair into a walker, and then motoring around the halls on the new knee). Plus, I did assisted flexion exercises by sitting in a wheelchair and rolling “over” the new knee so that it was bent >90 degrees. Because of my height and the length of my legs, I found this relatively easy, and was >90 on knee-plus-one day. Similarly, I was able to walk in the walker with relative ease. PT occurred at 10 AM and at 2 PM. After breakfast and before lunch.

Occupational therapy occurred after PT on Thursday. The therapist taught me how to go from a walker to a dining room chair; from walker to toilet; from walker into shower. Very simple, very practical and very functional. OT was an impressive operation, preparing the post-surgical patient for all of the things that they would face, from “Where do you put the walker when you are in front of the frig?” to “How do I get from the walker to the shower or toilet?”.

Getting out of bed was still a chore, thanks to all of the tubes and bags. But I could readily swing my legs over the side of the bed. I could also lift my leg-and-new-knee (straight leg lift) almost immediately after surgery.

Nurses and the surgeon’s PA indicated that I should expect to go home on Saturday (knee-plus-three days). On Thursday (knee-plus-one), this seems like it will be a stretch. Maybe Sunday.

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.

Knee-day: operating and recovery rooms

Knee-day: Wednesday, 29-Sep-2004:
Operating Room:
I had no recollection of going INTO the OR. However, I woke up in the OR as the team was cleaning up. There was a blue cloth drape in place at my waist that was about 18 inches high, just high enough that I could not see over it as I lay flat on my back. Someone from the surgical team noticed that I was awake, and the surgeon looked up and said “Hi -- everything went really well. You had one very ugly knee. We’re just finishing up. I’ll see you in recovery.” Then I was back out. My guess is that the anesthesiologist backed off on the sedation as the surgery was being completed, allowing me to wake up, and then took me back under.

Recovery room:
The surgeon talked with my wife, told her that the surgery went extremely well, and that mine was the 3rd or 4th worst knee he had ever seen. Apparently, there were many floaters and “spurs”, ranging from golf ball-sized on down to sand and gravel-sized pieces. It is standard practice to count the pieces as they are removed. When my count got to 20 pieces, they were down to gravel-sized pieces, and just flushed the remainder of them out, declaring them to be “TNC” ---“Too numerous to count”. The total count of things removed was >100.

In recovery, the surgeon later told me the same story, almost word-for-word, but also told me that he took out the entire synovial membrane. It was so irritated and inflamed that it resembled a piece of old leather, scarred and thickened. All of the “gravel” simply ground at the membrane, keeping it in constant irritation. He said that my body was already rebuilding the synovial membrane, giving me a brand-new one.

I said the word “osteophyte” out loud, and he went on about how some of the pieces were attached, and that some were floating, but that all were removed. He was able to remove so much of the spurring that he was able to use an implant that was 4 sizes smaller than originally planned (from the X-rays). This was one more good reason for the manufacturer’s rep to be in the OR. In all, my new knee was 4 inches thinner than my old knee.

And then he left the recovery room. I don’t remember much after that until I got to my hospital room.

Knee-day: anesthesia suite

Knee-day, Wednesday, 29-Sep-04:
Anesthesia suite:
I met yet another nurse, and answered a series of questions. I met the anesthesiologist. We talked about anesthesia options. Since I have a clear history re anesthetics, he suggested the use of a spinal/epidural. I would be sedated to the edge of unconsciousness during surgery, with the spinal to initially block the pain, and the epidural to manage the pain after that. The epidural would then remain in place for a few days during recovery, allowing for button control for pain. This was referred to as PCA, which is (I think) patient-controlled analgesia. I simply thought of it as “the button”.

The surgeon came came into the anesthesia suite, and chatted about what would occur. I was asked to sign an authorization to allow the “manufacturer’s rep in the OR”. Having access to a full inventory of parts within the OR during surgery sounded like a good idea to me. My new knee will be a Stryker Howmedica Scorpio.

The insertion of the epidural was simple. I sat up on the gurney. The nurse in the anesthesia suite washed my back with an antiseptic. I was given a sedative through the IV port, and told to lean forward. There was a very slight prick, and then ... I was completely out until after surgery.

This is it --- knee day arrives: pre-op

Knee-day: Wednesday, 29-Sep-2004:
I woke up, showered, and took my normal AM meds with a sip of water. Then it was on to hospital. I checked in, and was escorted to the surgical waiting room. We watched CNN for a few minutes, and then ...

Pre-op suite:
A nurse came and walked me into the pre-op suite. She looked at my chart and said “Just to verify the plan, you are scheduled to have both knees replaced, right?” Panic attack! I was supposed to only have my right knee replaced. Fortunately, the bilateral indication was only on the OR schedule, everyone else involved had it right --- unilateral, right knee only. I gave a urine sample. I was asked to move my bowels if possible.

And then I took off my street clothes, and put them into a bag (which apparently stayed with my gurney). Put on a hospital gown. A nurse shaved my right leg with a disposable electric razor (3M brand). It was not a terribly close shave, and the nurse and I talked about this change in surgery prep. The first of many BP checks occurred, and then an IV port was placed in my left hand.

And then ... I waited. I watched CNN, and my wife was eventually allowed to wait with me. I told the nurse that I had brought my normal prescriptions with me for that evening and for the remainder of stay. She said that the surgeon would prescribe matching meds from the hospital pharmacy for the duration of my stay. She gave no explanation --- my assumption is that patient-provided meds could be adulterated, or in error. This way, the hospital is fully responsible for the meds, since they are the ones doing the dispensing. This is an understandable legal/ethical position.

There was a phone call. “They’re about ready for you”. I get onto a gurney and am wheeled into the anesthesia suite. My wife kisses me on the cheek and goes back to the waiting room.

Tuesday, September 28, 2004

Are we nervous yet? Knee-minus-one-day

Knee-minus-1 day, Tuesday 28-Sep-2004:
Finally. I called to find out my OR schedule. Surgery is scheduled for 910; I was to arrive at 710. Nothing to eat or drink after midnight --- typical pre-op instructions. Nonetheless, I had a very restless night --- anxious to get it over with.

Sunday, September 26, 2004

Getting ready? Getting fret-ty.

Knee-minus-3 days, Sunday 26-Sep-2004:
Three days to go, so I packed my bag for hospital. I made a run to the local libraries, and brought home 3 shopping bags of books to read during recovery (1/3 technical, 2/3 novels).

I fretted over general versus epidural anesthesia, and called the surgeon’s assistant. She said “We use epidurals almost exclusively”. Well. That cleared that up easily enough.

I also fretted over having a Foley catheter inserted --- until I learned that the insertion typically occurs after anesthesia. “You won’t feel a thing, or even remember having it inserted”. Well, OK, I guess.

I watched web videos of TKR surgery. I looked at web images of TKRs, both in photo and graphics forms. I compared brands. I read NIH reports. I dug into the research literature about TKRs, about antibiotic prophylaxis, about DVT therapies.

And then, I just stopped. The surgery was scheduled. I had very high confidence in my surgeon, the practice he is part of, and our local hospital. I stopped preparing for the worst, and started trying to think about how to prepare for the best.

Wednesday, September 15, 2004

Pre-admission screening

Knee-minus-14 days, Wednesday 15-Sep-2004:
Pre-admin testing. These turned out to be typical clinical examinations of urine and blood. I had both an ECG and a chest X-ray. I met with a nurse who walked me through the details of a three to five-day stay in the hospital. What to wear, what to bring, what not to bring. I also had repeated opportunities to ask questions.

I then got a little neurotic, having been pummeled with information about the risks involved in surgery, in hospital stays, with anesthesia. I promptly went back to work and and developed contingency plans both for my business and for my home. We reviewed our wills, and power of attorney documents.

I also spent lots of time on-line digging into potential TKR complications, how to recognize them, and how to avoid them. Happily, I can now state that none of them happened with me.