Once settled into my hospital room, I found myself hooked up to the now familiar but inadequate PCA morphine pump. I thought we had clearly established the advantages of mainlining Dilaudid over a morphine drip way back in the recovery room. This couldn’t possibly be happening.
The little button attached to the PCA lit up at regular intervals indicating that I could push the button for my next dose. Knowing that all available peace and goodwill on earth were currently flowing from the morphine pump, I developed an instant and deep seated fixation on the button. This prevented me from doing anything remotely useful such as transcribing Braille or making cold calls for the Democratic National Committee. I started playing clever little games with the button such as trying to push the button milliseconds before the light came on to see what the reward would be. Sometimes I’d push the button in rapid fire succession and other times I’d just push it really, really hard. Perhaps I’d fool the machine and get an extra dose. Sounds crazy, but in my mind, it was definitely worth trying. I sat there contemplating how it was possible that once again I was feeling unbearable pain yet my only response was to push a little button at regular intervals for a less than adequate reward.
For a brief period, I became a lab rat pushing the button… pushing the button… pushing the button while the doctors and nurses stared down into my cage. “He is a persistent little bugger! I wonder how long he’ll continue in this manner before he develops alternative strategies?” asked a nurse. A doctor replied, “oh, I’ve seen the brain injured subjects push the button until they wear their little paws to the bone. I hope this one tires before that happens.” I awoke to the sound of the PCA emitting a longer than usual beep and then I realized my knee was about to combust and my pain scale was at an 8 – or was it a 9? I was so confused. One thing I was fairly sure about was that those titanium screws in my Patella were working themselves through the bone and scraping against my tendons. I buzzed the nurse who finished up her dinner, went to the bathroom, washed her hands (thank God!), went out to the vending machine, finished her charting, chatted with Rosie who I had caught, just moments before, eyeing my untouched pudding, and then rushed breathlessly into my room. I cried out, "my PCA is broken, I swear to God, it's really broken, it doesn't work, it hurts, it hurts!" She looked at the morphine pump and told me it was working fine and left the room before I could muster another volley of complaints.
I sat there stunned but the nurse did eventually come back to look at the PCA again. “Well,” she said, “you have maxed out your morphine drip. Looks like you won’t get any more for an hour.” I thought she was joking and then realized that not only was she serious, she wasn’t presenting any possible alternate solutions such as acupuncture or music therapy and furthermore, it appeared that the punishment for morphine gluttony was deprivation for an entire hour. The nurse walked out of the room.
I buzzed the nurse once again. This time I convinced her that I needed something stronger than the morphine drip and the alternative she was presenting, no pain meds at all, was not acceptable. She called the doctor who thought that a 12 hour slow release pain med might do the trick. In the meantime, she gave me two Percocets in the hopes of keeping me off the buzzer. I took the Percocet and then settled back to watch the clock. After three hours and fifty nine minutes, I buzzed the nurse and asked for the 12 hour extended release pain med. “Oh no”, said the nurse, “the doctor has that scheduled for nine o’clock and it’s only seven. You will have to wait for two hours.”
“OK,” I said, “I started by asking for better pain management than the PCA provided and you told me that I would have to wait for one hour with no pain meds. Now you tell me that I have to wait two hours for a better pain med. The more I ask for pain meds the less I get. Is there some logic operating here that I’m missing?” That is what I wanted to say. What I really did was beg, cry, and plead and finally closed the deal with an offering of chocolates. The nurse agreed to ask the doctor if he could move the administration of my meds up two hours as she walked out of my room with an entire box of Belgian chocolates. The rest of my hospital stay was tolerable – which is all I really wanted.
Lessons learned:
• Nurses work with people in pain all day every day. They are not easily impressed by your sorry tales of woe and, depending on the seriousness of your condition, they are not easily convinced that you are able to trade sex for pain meds.
• When a nurse leaves your room, don’t assume she just got interrupted and will be right back. They do that when they don’t want to hear you whine anymore.
• Doctors hold the drugs – not nurses. Figure out ways to get the doctor on the phone or in the room. They are very busy so if you start on a long-winded explanation of why you need more pain meds, they will very quickly break down, scribble a script and leave. They feel good, you feel good – truly a win-win situation.
• If the hospital staff gives you control of your own drug administration, you can safely assume the drugs are absolutely and unequivocally ineffective. Why else would they give them to you to self administer? The reason that PCA has become popular is that doctors know most people will not yell at themselves when the drugs they are giving to themselves are not the least bit effective.
• Even though there are no signs prohibiting it, don’t try and take apart or increase the throughput of the PCA. The resulting long tone and flat lines on the display are not signs that the gates are open and the drugs are flowing… and those machines are expensive!
• Try not to talk about getting more effective pain medication too much or people will think you are becoming dependent.
• One of the best ways to show your support for friends and family members who are recovering from surgery is to bring small meals and small envelopes with left over pain meds you may have found in your medicine cabinet. Don’t worry about expiration dates. This lets the hospital off the hook and lets the doctors focus on more important things like golf.
Wednesday, January 27, 2010
Thursday, January 21, 2010
4 - Pain Management Part I
I awoke in the recovery room after my anesthesia wore off. I was immediately overcome with a sharp and unrelenting pain in my knee that only got worse as the seconds passed. Nothing had prepared me for this level of pain. I underwent back surgery twenty years ago and time certainly dulls the memory of pain but I didn’t recall ever demanding more pain meds and screaming viciuously at the nurses after my back surgery. I suppose age has given me the ability to clearly, if not inappropriately, express my needs.
I dominated my nurse’s time and she eventually had to call for help since I wouldn’t allow her to leave me in order to attend to the other cooperative, clean speaking, comfortable, quiet and apparently painless people lying in beds on either side of my mine. As I writhed in pain and blurted out all kinds of obscenities, my nurse kept trying to get me to breathe and relax. I tried my damndest to comply but controlled breathing and relaxation would not come to me for more than a few seconds before I started crying out again.
My nurse asked me what level of pain I was experiencing. I was dumbfounded. I thought I had been screaming my exact level of pain from the moment I regained consciousness. Did she not hear me? Perhaps she was a volunteer from one of the local group homes. But I wanted medication and only she could provide it so I stopped and pondered and decided that if I were on the battlefield and all my limbs had just been blown off, I would have to be at a pain level of 10. I, on the other hand had all of my limbs and I was still able to use language (be it filthy or not) to communicate and was not in shock so, to be fair, I gave myself an 8. “Well that’s not so bad”, said the nurse. “You are acting like it hurts a whole lot worse than a pain level of 8.” “OK,” I countered, “I’m at a 9.” “But you just said you were an 8,” she replied, "which one is it?" I thought maybe, just maybe, I was in kindergarten hell. “My pain meds are not working!” I screamed.
They had me on a PCA morphine pump which lit up to indicate I could press the button like a good little rat to get another burst of morphine. Nice idea, but to work effectively on my pain, it would have had to light up every 20 milliseconds or so. Finally another nurse came over and held my hand and stroked it gently as if I were a little kid and I responded like a little kid. I wanted her to hold and stroke my hand for the rest of my stay. I was able to calm down enough to tell them, without interjecting a single swear word, that I needed some pain meds that worked – NOW. The nurse called a doctor over who said, “It looks like his nerve block wore off a lot sooner than we expected. Let’s put him on Dilaudid.” Finally, a voice of reason came down from the heavens. Yeah, what a great idea! Maybe I could use some Dilaudid. Twenty minutes later I started breathing more regularly and I was able keep more of my thoughts to myself. My nurse noted my newfound disposition and said, "See, all you had to do was relax and control your breathing." I tried to respond but all I could manage was a little smile as I slipped into a restful sleep.
I dominated my nurse’s time and she eventually had to call for help since I wouldn’t allow her to leave me in order to attend to the other cooperative, clean speaking, comfortable, quiet and apparently painless people lying in beds on either side of my mine. As I writhed in pain and blurted out all kinds of obscenities, my nurse kept trying to get me to breathe and relax. I tried my damndest to comply but controlled breathing and relaxation would not come to me for more than a few seconds before I started crying out again.
My nurse asked me what level of pain I was experiencing. I was dumbfounded. I thought I had been screaming my exact level of pain from the moment I regained consciousness. Did she not hear me? Perhaps she was a volunteer from one of the local group homes. But I wanted medication and only she could provide it so I stopped and pondered and decided that if I were on the battlefield and all my limbs had just been blown off, I would have to be at a pain level of 10. I, on the other hand had all of my limbs and I was still able to use language (be it filthy or not) to communicate and was not in shock so, to be fair, I gave myself an 8. “Well that’s not so bad”, said the nurse. “You are acting like it hurts a whole lot worse than a pain level of 8.” “OK,” I countered, “I’m at a 9.” “But you just said you were an 8,” she replied, "which one is it?" I thought maybe, just maybe, I was in kindergarten hell. “My pain meds are not working!” I screamed.
They had me on a PCA morphine pump which lit up to indicate I could press the button like a good little rat to get another burst of morphine. Nice idea, but to work effectively on my pain, it would have had to light up every 20 milliseconds or so. Finally another nurse came over and held my hand and stroked it gently as if I were a little kid and I responded like a little kid. I wanted her to hold and stroke my hand for the rest of my stay. I was able to calm down enough to tell them, without interjecting a single swear word, that I needed some pain meds that worked – NOW. The nurse called a doctor over who said, “It looks like his nerve block wore off a lot sooner than we expected. Let’s put him on Dilaudid.” Finally, a voice of reason came down from the heavens. Yeah, what a great idea! Maybe I could use some Dilaudid. Twenty minutes later I started breathing more regularly and I was able keep more of my thoughts to myself. My nurse noted my newfound disposition and said, "See, all you had to do was relax and control your breathing." I tried to respond but all I could manage was a little smile as I slipped into a restful sleep.
3 - Expectations
My surgeon had the X-rays of my left leg up on the wall and was explaining to me, “see, here is one part of your Patella and look down here, there’s the other part!” I was so glad he found it. I didn’t want to start rooting around down there for lost bone fragments. My confidence in this doctor was jacking up by the minute.
My injury occurred Sunday, I was talking to the doctor on Monday and would be in surgery on Friday. I had no idea how long the next four days would be or how much worse the post surgery pain would be than those days preceding surgery. But, in the meantime, I wanted to know what my future would hold since I had some plans that definitely included bringing my knee along.
I told the doctor that I didn’t have much paid time off coming to me and short term disability only pays 60% of my salary so I was eager to get back to work in about two weeks. He should have laughed hysterically and, to better make his point, he should have rolled around on the floor and guffawed. But, I guess he is the kind of guy who doesn’t like to “dash one’s hopes” so he said that going back to work within two weeks was within the range of possibility. He then told me about a fellow orthopedic surgeon who had his Patella surgically repaired and was back doing surgery on others within two weeks. I was impressed and motivated. I too wanted to do surgery on others.
Much later in my rehab, my doctor told me the rest of the story about his fellow surgeon. Yes, he was back at work in two weeks only in the sense that he was resting and icing his knee up until the point where he hobbled into the operating room, performed his surgery in 1.5 hours and then had to lie down, elevate the leg, ice his knee and rest. Kind of what I was doing at home except I was allowed to take pain meds. And in fact, the doctor’s knee started to tighten up while keeping up this schedule, rehabilitation slowed to a crawl, so to speak, and some adjustments in his scherdule had to be made. Basically he managed to cut the surgery time down to ten minutes per patient without increasing his mortality rate more than 10% - well within the state surgical guidelines. I was disgusted with my doctor’s slow revelation of the “real” story and immediately cancelled my medical degree correspondence course. I thought the doctors were gods but really, they are a bunch of guys who feel pain like the rest of us.
My next question for the doc was about my prognosis further into the future. I had a backpacking trip planned for April first – three months down the pike - and I wanted to know if this was absurd or could I still look forward to this as a possibility - a goal to work toward. The doctor was speechless and just stood there staring at me. I knew then that he saw something special in me. His eyes seemed to say, “John, you are no mere mortal. I can sense in you a force far beyond anything I have ever known. Your strength will return and you will climb that mountain and you will throw off the burden of self-doubt and cast off the yoke of weakness for that mountain top will be yours”! I returned his gaze with an intensity that acknowledged his assessment and I nodded to show I understood. He laughed and I too laughed – we both laughed in the face of pain for I knew not what it was.
My injury occurred Sunday, I was talking to the doctor on Monday and would be in surgery on Friday. I had no idea how long the next four days would be or how much worse the post surgery pain would be than those days preceding surgery. But, in the meantime, I wanted to know what my future would hold since I had some plans that definitely included bringing my knee along.
I told the doctor that I didn’t have much paid time off coming to me and short term disability only pays 60% of my salary so I was eager to get back to work in about two weeks. He should have laughed hysterically and, to better make his point, he should have rolled around on the floor and guffawed. But, I guess he is the kind of guy who doesn’t like to “dash one’s hopes” so he said that going back to work within two weeks was within the range of possibility. He then told me about a fellow orthopedic surgeon who had his Patella surgically repaired and was back doing surgery on others within two weeks. I was impressed and motivated. I too wanted to do surgery on others.
Much later in my rehab, my doctor told me the rest of the story about his fellow surgeon. Yes, he was back at work in two weeks only in the sense that he was resting and icing his knee up until the point where he hobbled into the operating room, performed his surgery in 1.5 hours and then had to lie down, elevate the leg, ice his knee and rest. Kind of what I was doing at home except I was allowed to take pain meds. And in fact, the doctor’s knee started to tighten up while keeping up this schedule, rehabilitation slowed to a crawl, so to speak, and some adjustments in his scherdule had to be made. Basically he managed to cut the surgery time down to ten minutes per patient without increasing his mortality rate more than 10% - well within the state surgical guidelines. I was disgusted with my doctor’s slow revelation of the “real” story and immediately cancelled my medical degree correspondence course. I thought the doctors were gods but really, they are a bunch of guys who feel pain like the rest of us.
My next question for the doc was about my prognosis further into the future. I had a backpacking trip planned for April first – three months down the pike - and I wanted to know if this was absurd or could I still look forward to this as a possibility - a goal to work toward. The doctor was speechless and just stood there staring at me. I knew then that he saw something special in me. His eyes seemed to say, “John, you are no mere mortal. I can sense in you a force far beyond anything I have ever known. Your strength will return and you will climb that mountain and you will throw off the burden of self-doubt and cast off the yoke of weakness for that mountain top will be yours”! I returned his gaze with an intensity that acknowledged his assessment and I nodded to show I understood. He laughed and I too laughed – we both laughed in the face of pain for I knew not what it was.
2 - Cancellations and adjustments
Two nurses came into my hospital room and one began to examine me. I could tell something was amiss when they started whispering to each other in hospital code – clearly they intended to cut off my leg and didn’t want to alarm me or cause undue distress. While one of them traced her finger along what now revealed itself to be the jagged edge of my Patella I started to understand that just maybe we weren’t dealing with an errant but adorable little Patella here. Maybe, I thought … and then I saw the other nurse move her hand much too quickly toward my knee and I grabbed her wrist in a death grip before she could touch me. My eyes locked on to hers and sent a very clear message that I could snap her forearm at will. She calmly asked me to let go so that she could help examine the line of fracture. So that was it: I had a fractured Patella – it wasn't dislocated after all.
As I sat with my family waiting to be discharged from the hospital, I used the time to prepare my son for the possibility that I could lose my job, rack up debts, go bankrupt, and end up homeless and living on the good graces of all those friends and relatives I had been ignoring for so many years. Things looked pretty bleak but I have never tried to shelter my family from the cold hard truth or at least my unbiased interpretation of that truth.
When I got home, I started to cancel some travel appointments. My son heard me cancel my trip to Washington DC before Christmas and my trip to Connecticut immediately after Christmas and he looked like he was going to cry. My heart really went out to him but I seized the moment - this was my chance to show some generosity and love without having to spend a single hard-earned dollar, “You know Corin, I really wanted to surprise you but this January, Mommy and I were going to take you to Disney World right after Christmas.” He couldn’t hold back any longer and tears burst out all over but I couldn’t help myself. “Yeah and then we were going to take a hot air balloon ride down to Cuba for a day. Now we’ll have to cancel all of those plans. I’m so sorry.” I torqued my knee a little to help muster up some tears of conviction.
Nice work! I could chalk Disney World off the list.
As I sat with my family waiting to be discharged from the hospital, I used the time to prepare my son for the possibility that I could lose my job, rack up debts, go bankrupt, and end up homeless and living on the good graces of all those friends and relatives I had been ignoring for so many years. Things looked pretty bleak but I have never tried to shelter my family from the cold hard truth or at least my unbiased interpretation of that truth.
When I got home, I started to cancel some travel appointments. My son heard me cancel my trip to Washington DC before Christmas and my trip to Connecticut immediately after Christmas and he looked like he was going to cry. My heart really went out to him but I seized the moment - this was my chance to show some generosity and love without having to spend a single hard-earned dollar, “You know Corin, I really wanted to surprise you but this January, Mommy and I were going to take you to Disney World right after Christmas.” He couldn’t hold back any longer and tears burst out all over but I couldn’t help myself. “Yeah and then we were going to take a hot air balloon ride down to Cuba for a day. Now we’ll have to cancel all of those plans. I’m so sorry.” I torqued my knee a little to help muster up some tears of conviction.
Nice work! I could chalk Disney World off the list.
Wednesday, January 20, 2010
1 - The fall - the beginning
So now that I have passed through the initial phase of healing, I have the energy to write about my experience shattering (that sounds so much more dramatic than "fracturing") my Patella. I learned that way cool name for "knee cap" on December 13, 2009.
Yes, I slipped on some black ice five weeks ago and all 215 pounds of me landed squarely on my Patella. I didn't experience the fall in slow motion or later on have flashbacks of slipping and falling while desperately reaching for support. Nope. I just slammed my left knee into the sidewalk and knew in a split second that this was serious. The first clue was the overwhelming and excruciating pain, the second clue was that my knee cap had worked its way up into the section of my leg normally reserved for my quadriceps and that it was also bulging just a bit out the side of my leg.
When I tried to move my leg, all hell broke loose. After a quick consultation with my family and a "Good Samaritan" who had pulled over to help, we came to an understanding that I would kill the next person who tried to touch, move or even glance at my leg. So I lay there on my sidewalk in front of my house with cars whizzing by and with rain coming down on me while my wife called an ambulance and grabbed an oversized umbrella, the Good Samaritan reassured me and my son procured some camping pads for me to lie on.
The guy in the ambulance did a good job of distracting me from my pain with stories of other accidents that were far worse than mine. "You should have seen it, her bones were poking right out the side of her leg", or, "this guy was so cut up he had to hold his own liver all the way to the hospital", etc. My knee cap was simply dislocated. The doctors would snap my Patella back in place in short order. What a relief! This would all be over in no time. The doctors would give me some good drugs and send me home to trim the tree in the company of friends and family. Not a bad way to spend a rainy, if not slippery, Sunday afternoon in December.
Yes, I slipped on some black ice five weeks ago and all 215 pounds of me landed squarely on my Patella. I didn't experience the fall in slow motion or later on have flashbacks of slipping and falling while desperately reaching for support. Nope. I just slammed my left knee into the sidewalk and knew in a split second that this was serious. The first clue was the overwhelming and excruciating pain, the second clue was that my knee cap had worked its way up into the section of my leg normally reserved for my quadriceps and that it was also bulging just a bit out the side of my leg.
When I tried to move my leg, all hell broke loose. After a quick consultation with my family and a "Good Samaritan" who had pulled over to help, we came to an understanding that I would kill the next person who tried to touch, move or even glance at my leg. So I lay there on my sidewalk in front of my house with cars whizzing by and with rain coming down on me while my wife called an ambulance and grabbed an oversized umbrella, the Good Samaritan reassured me and my son procured some camping pads for me to lie on.
The guy in the ambulance did a good job of distracting me from my pain with stories of other accidents that were far worse than mine. "You should have seen it, her bones were poking right out the side of her leg", or, "this guy was so cut up he had to hold his own liver all the way to the hospital", etc. My knee cap was simply dislocated. The doctors would snap my Patella back in place in short order. What a relief! This would all be over in no time. The doctors would give me some good drugs and send me home to trim the tree in the company of friends and family. Not a bad way to spend a rainy, if not slippery, Sunday afternoon in December.
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