Sunday, October 31, 2004

Slant board design and construction

Knee-plus-32 days, 31-Oct-04, Sunday:
I made a slant board for stretching today. Very cool. I had reached my positive limit re calf stretches with the towel, and fell in love with the stretch board at the PT suite. Simple simple concept, but very effective.


I'll take a photo and try to insert it here. The slant board is just a simple box. A 1x8 board forms the high end (the back). A piece of 3/4" plywood forms the surface for your feet, and slants from the top of the back to flat on the floor. A second 1x8 is ripped on the diagonal to form two triangles which become the sides. The plywood top is screwed to the sides and the high-end (back). I cut a belt sander belt in half to form two traction strips for my feet.

Why did I do this? I was not able to get a good stretch and extension any other way. I can now stand on the slant board, lean forward from my ankles (towards a wall to keep me from falling over) and REALLY stretch out the back of my knees. This is wonderful.

2X full sets AHPT, including the bike. 1X mi walk.

Saturday, October 30, 2004

Driving solo, at last

Knee-plus-31 days, 30-Oct-04, Saturday:
I drove into town to get a haircut. By myself. 2 sets AHPT, including 15 min bike, 1 mi walk.

Friday, October 29, 2004

Freedom!!!

Knee-plus-30 days, 29-Oct-04, Friday:
Freedom! Very happy day after the meeting with the surgeon. He was extremely pleased with my progress. No more TED stockings. No more warfarin. I am now permitted to drive. Had X-rays done --- implant looks very very good. The quote of the day: “If you had taken four months to get to this point, I would have been happy. To have done it in a month, especially considering how bad your knee was when we operated, is pretty amazing.”

The next two months / 10 weeks are apparently more of the same battle. Keep the knee as mobile as possible by working constantly. Begin to build strength. Walk more, bike more, but continue ALL of the ROM exercises. Surgeon does not need to see me for 3 months, but expects me to work out a reasonable schedule of AHPT exercise with PTist. He doesn’t care if I go to PT 1X or 3X per week, so long as the daily AHPT continues as it has been.

Thursday, October 28, 2004

When will I ever get a good night's sleep?

Knee-plus-29 days, 28-Oct-04, Thursday:
The night was much improved, although I still was awake repeatedly. Normal AHPT sequence, including a 1 mile walk over lunch.

I went to work for 90 min, then came home, iced down. We’ll see.

Wednesday, October 27, 2004

Oxycontin withdrawal

Knee-plus-28 days, 27-Oct-04, Wednesday:
Very rough night for sleep. Up every 90 min to 2 hrs. My wife thinks that it’s oxy-withdrawal. She could be right. I definitely felt itchy creepy-crawley all night long.

I called the surgeon (and received) a fresh percocet scrip. There is still too much rehab pain to not continue percocet while I remain on warfarin.

My leg is very swollen above the knee. There are no reasons to think “blood clots”, just swelling from exercise. That and sitting upright at work for 2 hrs with the knee bent and below my waist. My wife convinced me to not go to work today --- she’s probably right.


PT was pretty standard. I do not have the ROM that I want, thanks to the swelling. But progress continues.

Tuesday, October 26, 2004

Slacking off = loss of progress

Knee-plus-27 days, 26-Oct-04, Tuesday:
Returned to work for 2 hours. Today was the last oxycontin. Had been thinking about backing off the percocets, but not if I need to keep pushing on the AHPT.

My PT conclusion is that the knee “seizes up” very quickly if you slack off at all on the AHPT. The pillow under the knee may feel good, but even one day can cause loss of extension-ROM. Kind of stunning at how quickly things can change.

The new regimen is PT in the AM; work in the afternoon; PT after work. Don’t know what I will do once I am working full-time. Maybe the body won’t be trying so hard to limit ROM by then.

Monday, October 25, 2004

Tell me again how you measure with that thing?

Knee-plus-26 days, 25-Oct-04, Monday:
PT. Variation in goniometer use by PT-ist? Today’s PTist measured me at 105 active, 115 passive. She did the bending on the pad, rather than letting me use the wall.


Returned to work for 2 hrs. Did not do AHPT after work. Came home, and crashed.

Sunday, October 24, 2004

Slacking off for another weekend of football and houseguests

Knee-plus-25 days, 24-Oct-04, Sunday:
Normal Sunday --- up early, read the papers over coffee. Did AHPT 1X (one full set, including 30 min on bike), and did not walk.

Knee-plus-24 days, 23-Oct-04, Saturday:

Another weekend of guests. Did AHPT while the football gang was tailgating, but did not walk.

Friday, October 22, 2004

Making progress

Knee-plus-23 days, 22-Oct-04, Friday:
Good PT. 115 degrees flexion active; 123 degrees passive. The end goal is 125. Walked 1 mile.

Knee-plus-22 days, 21-Oct-04, Thursday:
Good night sleep. Awake only once.


Quiet day. At-home PT. Walked one mile. Walking uses a different set of muscles than biking --- I had to stretch out after walking by riding the bike for 10 min!

Wednesday, October 20, 2004

The end of the pain?

Knee-plus-21 days, 20-Oct-04, Wednesday:
Good PT. Made 123 degrees (passive, with pain). 116 active, pretty much without pain. At-home PT yesterday included 3 full sets, and 3x3x5 (30 min) on the bike, each time. This was really tiring, but appears to be effective.

Sleep last night was good. Up twice, but fell back to sleep readily.


New scrips at the pharmacy. These should be the last ones, I hope. The plan is to stop oxycontin when current lot runs out (Sunday, I think), and then run this lot of percocet out til it’s gone. By then, I should be off of the warfarin, and able to resume ibuprofen. If I need anything at all. Right now, except for the exercise pain, there’s very little pain left to handle.

Tuesday, October 19, 2004

I need more drugs

Knee-plus-20 days, 19-Oct-2004, Tuesday:
Today is the first day where I attempt to run 3 full sets.

Sleep last night was decent. Two awake periods, one at 1-ish, a second at 3-ish. I doubled the oxycontin, trying to break through the pattern, but could sense no real difference. I reduced evening fluid intake which may have helped (increase in AM, decrease in PM).


I need a new percocet scrip, since I am about to run out. 2X regime may be helping get me through PT, but it burns through the pills.

Monday, October 18, 2004

When can I go back to work?

Knee-plus-19 days, 18-Oct-2004, Monday:
Sleep last night was much improved. I reduced fluid intake last evening, and backed off on the percocet (1 tab at 730 AM, and then none until 1 AM, and then nothing until 730 AM Monday).

PT went smoothly. Did a reduced set pre-PT (at home), and loosened up by slowly working on the bike. The PTers did a "re-assessment" (OKing additional authorization from insurer) --- I was making good progress. Target for this week is 120 degrees flexion. Today, active flexion (my control) was at 110. Added mini-lunges to routine.

I would like to do a full set 3X a day this week. 9 AM, 1 PM, 5 PM. Maybe one of those should be replaced with a walk down the block.

When will I go back to work? My wife is thinking the first week of November. I hope to get in some hour-at-a-time time next week.


Next week’s surgeon visit should let me stop wearing TED hose, and should let me stop taking warfarin. Once I am off the warfarin, I can taper down on the percocet and oxycontin, eventually going back to good ol’ ibuprofen.

Sunday, October 17, 2004

Pain meds and constipation

Knee-plus-18 days, 17-Oct-2004, Sunday:
Another home football game, another weekend of company, and another weekend of minimal exercise. I did do a full set in the AM, but only biked in the PM.

Knee-plus-17 days, 16-Oct-2004, Saturday:
2X percocet regime may be working for pain control and PT, but it is wreaking havoc with my digestive system. It took an incredible amount of exertion and >50 min on the toilet to move my bowels today. Finally did it, but it was exhausting.


Residual gut pain from the effort continued all day, and into Sunday
.

Friday, October 15, 2004

Finally making progress with PT

Knee-plus-16 days, 15-Oct-2004, Friday:
PT went well. I could do 116 degrees “active” (unassisted), and 120 “passive” (with the PTist pushing the relaxed leg until I couldn’t handle any more pain). I also got the PT recumbent bike to go around for the first time. The therapist was both surprised and impressed with the progress that I made in the past 2 days. I am convinced that a) it was the bike, and b) that by doing a reduced set of exercises before going to PT, including loosening up on the stationary bike, I could get loose enough to meet his expectations. Next week’s goal is 120 active.


I did a second full set in the PM. Bike is 2 min forward, 2 back, repeated 3X.


[Looking back, this second week post-op was a "breakthrough" week all around]

Thursday, October 14, 2004

I hate PT, I love PT

Knee-plus-15 days, 14-Oct-2004, Thursday:
Wednesday PM PT was also agony. The residual pain post-PT was intense. I doubled the percocet regime (2 tabs every 4 hrs) --- still within the instructions on the bottle.


Wall slides are simply not very easy to do in this house. I can slide my foot down the wall until I have to scream, but I am still not convinced that I am getting enough flexion. Therefore, I brought out the stationary bike, and began to work with it. I raised the seat until I could make the wheel go around, and then just kept working at it until I could make circles repeatedly. Afterwards, my knee feels looser than ever before, and with good ROM.

Blood flow from the right leg also seems to be better, and the swelling has gone down. That could be from using ice non-stop when not exercising, though.

Wednesday, October 13, 2004

What's that HUGE bruise on the back of your leg?

Knee-plus-14 days, 13-Oct-2004, Wednesday:
Knee-plus-2 weeks!

I scheduled my AM oxycontin and percocet to “peak” during PT.

PT today was absolutely brutal. My PTist could force my knee to 105 degrees, but I screamed in pain when he got it there. I left PT determined to get it there myself, and by Friday. It is ever so much easier for me to hurt myself than to let someone else do it to me.

The PTist also taught me to do wall slides to improve ROM. Butt about 3 ft from the wall; feet up high on the wall. Bend knee by sliding foot downwards to bed. Use other leg to push/pull it down the wall. This is agony, but it also seems to be effective.

Again, the only thing stopping me from better ROM is pain. And continued swelling.


After my shower today, I noticed that there was a huge bruise on the back of my right thigh!! No pain though, and neither pain nor “heat”. Nonetheless, I panicked. I immediately called the surgeon’s office and got his PA. Duh. The bruise is from the tourniquet which was on my leg during surgery. Of course, there’s a bruise, since I bled profusely after the tourniquet was released. It was a deep bruise and on the back of my thigh. I have only been taking showers for a day. I simply didn’t see it during the sponge baths.

Tuesday, October 12, 2004

First shower

Knee-plus-13 days, 12-Oct-2004, Tuesday:
Today was first shower day. With the staples out, I felt very comfortable taking a shower. Ahhh. We had installed a heavy-duty support bar in the first floor shower before my surgery --- this was a good idea.


I added side-steps and backwards-steps across the house to the AHPT routine. These are not yet called for by formal PT, but there are people ahead of me in the process doing these, and it makes sense. The ligaments and tendons that were loosened during surgery need to be strengthened and tightened.

Monday, October 11, 2004

Ice is your friend

Knee-plus-12 days, 11-Oct-2004, Monday:
Happy birthday! Today, I am 51 years old.

PT in the AM. I can almost get the bike wheel to go around. I think that if the seat is just a little farther back, I can do this. Regular PT routine --- flexion (ROM) is still really tough, though.

I met with the surgeon in the PM. It was a quick visit. Staples were removed. Simple, painless. Incision was covered partially with little SteriStrips, but these seem to have no real function.


The surgeon was pleased with my progress, but wanted more PT. He was unhappy that I was only going to PT 2X a week; and changed that immediately back to 3X/wk. He told me that if the PTers were not hurting me, they weren’t doing their job. He said that I could not damage the new joint, that all I could do was to cause myself hurt (i.e., exercise-caused muscle pain) and that this was both expected and necessary. The only thing limiting my flexion ROM was pain and swelling. Pain should be controlled by meds; swelling by ice.

“Ice is your friend”.


The surgeon was also surprised that no one had told me to go to the hospital for coag time monitoring, and set that up immediately. I went to the hospital immediately after the appointment to bleed.

Sunday, October 10, 2004

It must be the meds

Knee-plus-11 days, 10-Oct-2004, Sunday:
It is very curious at how little reading I am actually getting done. It must be the meds reducing my ability to focus.

Saturday, October 09, 2004

Weekend house guests do NOT mean you can relax

Knee-plus-10 days, 9-Oct-2004, Saturday:
I got a haircut today. My wife called the barber and set it up so that the barber would meet us before the shop opened (7 AM), and get me done without waiting. Ahh. This felt good. I am still sponge-bathing, though. I am content to wait until the staples are out before I try doing the shower routine.


We have a full house of company this weekend and since I had such a rough PT day on Friday, I did very little today except for a walk my two blocks and back. This was probably an error in judgment. PT needs to have first priority, social responsibilities can come second.

As a point of reference, we live in a small town connected to a large college, with a large college football program. Our house is full of family, friends --- all alums or connected to alums. This is a wonderful experience. Every home football game becomes a family reunion, and an extended family reunion at that. However ... I was not terribly social this weekend.

Friday, October 08, 2004

Walking two blocks

Knee-plus-9 days, 8-Oct-2004, Friday:
PT was really brutal today. I am having trouble increasing the flexion angle. My knee is still very swollen. The PT team put me on the bike today, but only to work the knee --- there is no way that I could go completely around on the cycle. And the PT-ist really caused a lot of pain as he pushed my new knee further into flexion.


I walked two blocks back and forth. Walking is a lot more comfortable than PT.

Thursday, October 07, 2004

Look, Ma --- I'm using a cane!

Knee-plus-8 days, 7-Oct-2004, Thursday:
PT taught me to use the cane, instead of the walker. I walked in our neighborhood for 1 block and back. Cane goes to the ground with the right TKR knee, to assist in the support. This is the reverse of what I was doing pre-surgery. It may take me a little while to re-learn this one.

The folding walker was still a good acquisition. I use it for the p-bar exercises during AHPT, and very effectively.


BM continue to be difficult, with an “every other day” pattern appearing to develop. I am drinking fluids almost non-stop; eating Metamucil cookies 1X a day; taking Dulcolax 2X a day.

Wednesday, October 06, 2004

Really, it's the drugs talking

Knee-plus-7 days, 6-Oct-2004, Wednesday:
More of the same. Wake, sponge bath, breakfast, exercise, walk. Doze. Repeat. Sleep at night is pretty much on a 2 hr cycle. Pee, sleep, wake up, pee, take a pill, sleep. Repeat.


Checked in at work with my VP Operations. We talked for about 20 minutes. When I got off the phone, he immediately went to my wife and asked her what kind of drugs I was taking ... Obviously, I am not nearly as much in control as I think!

Tuesday, October 05, 2004

First official day of PT

Knee-plus-6 days, 5-Oct-2004, Tuesday:
First PT session. Standard exercises, plus some new things on the parallel bars. Abduction (foot to the side, both sides). Foot to the rear (both sides). Mini-squats [I noticed that I lean too much on the left (good) side, so I actually did a couple of one-legged squats on the right (TKR) leg, frightening the therapist]. Calf raises. Hamstring stretches.

Mat exercises included an interesting crossed-rope heel slide, and a calf stretch (quad set, but with a towel/rope under the ball of the foot, pulling back on the towel to stretch the calf).

I was told to bring the cane with me to the next PT session (Thursday). Told to focus on extension, that my flexion (ca. 95 degrees) was coming along fine.

There is a $30 per-visit co-pay with our Blue Cross plan. I squawked about the rate (figuring that it should be $30 per week, not per visit). The lead PT guy decided that I was far enough along (essentially working at the knee-plus-3 week rate on day 1) that I could reduce to 2X per week without harm.


I continued to walk around the driveway loop, 3X. And I duplicated the PT routine at home, once more today, and planning to do 2X per day, with or without formal PT
.

Monday, October 04, 2004

Walking the walker around the driveway

Knee-plus-five-days, 4-Oct-2004, Monday:
More of the same routine. I added more loops of walking around the driveway. I did AHPT 2X a day, plus quad sets whenever it occurred to me.

I called the surgeon’s office when they opened and scheduled the first follow-up appointment for 11-Oct. My first formal PT session is tomorrow. Apparently, PT is written as a scrip, and I could use any PTist from any practice that I choose. This is probably a billing issue --- PT is after all a separate service --- but it really made no sense to me to do the PT anywhere but at the practice where the surgeon is.


I felt so good that I checked into e-mail at work. No problems, but there was a lot of surprise that I was back at it.

Sunday, October 03, 2004

Up, down. Up, down. Up, down. All night long.

Knee-plus-four days, 3-Oct-2004, Sunday:
It was amazing how quiet it is at home, in comparison to the hospital.

Saturday night was full of naps and urinations. I slept for an hour or two or three, got up, urinated, took a percocet (if the schedule allowed), and went back to sleep.

At-Home Physical Therapy (AHPT) was a little frustrating. I had trouble figuring out how to flex the knee adequately (duplicating the wheel chair roll). Knee slides on the bed just were not giving me the flexion I could do in the hospital. The swelling I experienced after removal of the Ace bandage was still more than I was comfortable with. I began rolling an 8 or 9” plastic ball under my foot as I sat on the edge of the bed, and this seemed to work very well.
I walked around the driveway repeatedly (ca. 300 ft), using the walker. It felt good to be outdoors.

Saturday, October 02, 2004

Home!

Knee-plus-three days (2-Oct-2004, Saturday):
Saturday AM finally arrived. I bathed, packed and waited.

The surgeon’s PA and on-call partner came in; wrote me a handful of prescriptions (drugs, devices); and told me that a nurse would walk me through the remainder of the discharge process. However, I had to have one more PT session in the hospital before discharge. My leg had ballooned overnight, following removal of the Ace wrap. The doctor said that this was normal, and the swelling could take up to a month to go away. I needed to elevate my leg; keep it iced; and NOT put anything under my knee.

When I asked about follow-up appointments, PT, etc., I was given additional scrips and instructions to call the office on Monday.

Breakfast came. And then the PT person came by at 0900 to take me to PT. I was ready for release by 0930. The IV port was finally removed from my hand.

I was ready to go. So I called my college age daughter. And woke her up after she had just gone to bed.

My daughter and my mother (who now lives with us) came to pick me up at the hospital. A nurse took me in a wheelchair to the car, and we were off. We drove to a home health care supply store for a walker, a toilet riser, and TED stockings. Unfortunately, the TED stockings had to be ordered (I’ve got long legs), so I had to wear the same ones I used in the hospital until at least Monday. And the riser seat did not fit our toilet (my wife went to a building supplies store and replaced the entire seat). But the folding walker was great.

My daughter then went to the pharmacy to pick up the med prescriptions, only to discover that the warfarin scrip did not include dosage requirements. The pharmacist said “You’ll have to wait til Monday” and I panicked. Finally, after calling the pharmacy, the nurse’s station, and the physician’s answering service, the right connection was made, and all prescriptions were filled. Ta da.

Now, the problem was comfort at home. We live in a two-story house, but moved our bedroom to the first floor for the duration of my recovery. The “nest” we had made for me pre-surgery worked very well. However, the conflicting instructions that I was given by the surgeon (“elevate the leg”; “put nothing under the knee”) drove me crazy. We eventually hit upon building a ramp of pillows under the leg, from the thigh to the ankle, but with a gap under the knee. My knee and leg could then remain fully extended, yet be fully elevated. The “rule” stating “nothing under the knee” is intended to maximize the amount of time that the knee is in full extension. Yes, it will certainly feel better if you bend your knee and rest it on a pillow. However, this practice allows your knee to build up scar tissue (or muscle / ligament / tendon tightness) that keeps you from being able to attain full extension.


The remainder of the day was mostly spent with napping and trying to figure out how best to schedule pills and exercise. With both the percocet and the oxycontin, it took about 75 min from ingestion to noticeable reduction in pain. With both, I also tried to only take the minimum prescribed dose. I would later learn that this was an error in judgment.

Friday, October 01, 2004

Out, damned tubes ... out, I say!

Knee-plus-two (Friday 1-Oct-2004):
I started today again with real coffee from home. Yummm.

Morning PT was pretty much like Thursday’s (k+1). However, tubes and drains began to be removed after lunch. The Foley came out (hurray!); the IV was shut down (although the port remained for IV administration purposes); and the epidural was removed. Pain killer was switched to ketorolac (that’s the generic name), syringed into the IV port; percocet and oxycontin for pain control began by mouth.

Once I was “free” --- except for the wound drain --- I put on a polo shirt, and began to feel normal. PT was great --- I was able to walk the halls as I chose, and could do so even when back on the floor. At the end of the day, I was walking the halls by myself when my wife and daughter came to see me.

Removal of the epidural was excruciatingly painful, not because of the catheter but because I have a hairy back, which was not shaved pre-op. The epidural catheter was secured to my back with a large adhesive pad (ca. 9 in x 13 in) covering most of my back. Removal of the epidural was as simple --- and as painful --- as freeing one edge of the large pad, and slowly ripping it off of my back, from top to bottom. I did not feel the actual catheter leave my body, only the adhesive being torn off.

My family physician tracked me down in PT, so I had him check the epidural site. I could not believe that the epi cath was removed by yanking the adhesive pad from my back. There was no bleeding --- the doc could hardly find the insert location). He also cut out the Fe supplement.

I was interested to learn that a Foley catheter is “held in place” by inflating a small balloon (with sterile water, not air) within the bladder. The catheter is actually a tube-in-tube with the urine flow occurring in the inner tube, and inflation/deflation of the balloon occurring through the outer tube. The nurse simply used a syringe at the collection bag end of the catheter to completely deflate the balloon, and then --- tug --- and out it came. A little pressure, uncomfortable but no pain, as it slid out of the ureter.

Removal of the Foley meant that I had to demonstrate that I could urinate without the catheter. I rapidly filled a bottle for the nurse [I was drinking a LOT of fluids]. However, there was a small friction sore at the opening to the ureter which had been caused by the catheter rubbing on my clothing. The nurse said that this was common and should go away overnight (which it did).

Preparing for a Saturday departure also meant that I had to have a bowel movement --- or else. The threat was “BM by 8 PM, natural, suppository, or enema.” Whew. I came through but it was painful. The opiate-derived pain killers suppress normal peristalsis, and “bind you up.” I had almost never in my life been constipated, but had become quite constipated following surgery, even with all of the fluids I was consuming and 2X daily doses of a stool softener.

At the end of their evening rounds, the surgeon’s PA (and the weekend on-call partner) visited. They confirmed that I could go home on Saturday (they’d come in for the discharge early in the AM), and removed both the Ace bandage and the blood drain. Blood volume in the drain during Friday was ca.125 mL --- the desired threshold was 100 mL or less. This put the “pull the drain” decision in the hands of the physicians, not the nurses. But they did pull it.

My wife and daughter went home, and took with them everything that I didn’t need for Saturday. I had horribly over-packed clothing. Until the catheters came out, I wore a hospital gown. I wore long boxer shorts with no additional underwear (catheters, remember, until Friday afternoon). And as much as I expected to be able to read, I could not. The pain killers kept me from being able to focus much at all. I would read and re-read the same sentence repeatedly.

And then ...
My entire hospital experience changed with the beginning of the weekend staffing schedule. Until Friday evening, I had only positive things to say about the service in the hospital. Friday night certainly changed those perceptions.

I was given my PM meds, and “put to bed” by 10 PM. By 11 PM, the hallways appeared to be empty. The night shift nurse (and apparently, only one, rather than the two or more who had been assigned to our wing the previous two nights), came in, got distracted by my roommate’s demands for sleeping pills, and neglected to take my temp and BP. Then he disappeared. A puls-ox alarm went off down the hall, and continued to shriek for more than an hour. No response from the nursing staff. This continued to occur during throughout t entire night, Friday. If I had been in the room with that patient, it would have completely freaked me out. I “listened” to CNN Headline News all night long to block out the alarms from the hallway.