Surgery

Surgery went well. It turns out that I rather liked the spinal anesthesia. I had been worried about it but the pain control was awesome without any noticeable effects. I woke up feeling good, no nausea whatsoever, my dear wife provided the starbucks and as far as i could tell my body ended at the belly button. The first night was rather difficult because in addition to the normal interruption for vital signs, menu  orders, etc. my blood pressure decided to drop in the middle of the night. I felt good, without any signs of low blood pressure but no matter how they took it, my systolic was under 80mm Hg and diastolic was somewhere in the 40’s. Not something they were happy with. So they decided to take it more often–every fifteen minutes in fact. that was not conducive to any sleep whatsoever.

Then the results of my post op blood draw came back and I had dropped my hematocrit by 10 points. Which is the equivalent of 3 units of blood, not an insignificant amount. Still my overall level wasn’t too low and without symptoms they decided to recheck it in an hour or so to make sure it was not a lab error. NOPE. same reading, and again in the morning when they checked it again.

The surgeon was clear I had not lost much blood so it is a mystery where it all went to. some of it could be dilution. this occurs when we give a lot of IV fluids ( in my case to raise up the blood pressure) and the blood is diluted so the reading is erroneously low, but that does not explain all of it.

Nevertheless I still got out of the hospital the next day and made it home for my snake nightmare (see prior post). I remember the surgeon asking about pain and i was still doing well. He then said that would not last and I would be having severe pain soon. Not something one likes to hear. He gave me lots of narcotics, more than i thought was called for. let me tell you, I was wrong. I am normally hesitant to take such medicines but over that past week I have overcome that preference. The pain although only occasionally severe is continuous and persistent. it wears you down, then my mood goes and I don’t want to be around anyone. it gets in the way of doing my exercises. So despite the severe nightmares that I attribute to the narcotics, I lay them out and take them on time. Like I told my physical therapist, I had to resort to my last resort: following directions.

I have had one great day, two good days and several tough days. on the good days I wonder why I can’t go to work. on my bad days I wish i had never considered the surgery. On the plus side my physical therapist says I am way ahead on my mobility. On the minus side, I have a ways to go before i can resume my aerobic activities ( a huge anxiety reducer).

Yesterday I went to the office for a meeting and to do some paperwork. I felt great getting back into my routine. I even wanted to find a patient or two to see. But soon enough the fatigue caught up with me and by the time I got home i crashed for a couple of hours. It took the rest of the day to fully recover. I guess this is going to be harder than I anticipated.

Night wrestling

I am ten days out from my total knee replacement and there are many stories and experiences to relate. But first I wanted to begin not with the first event but one a few days after getting home, because it is funny, ironic and reveals much about the brain during dream sleep.

One of the most wonderful machines used in post surgical care is the ice water cooler. it is basically a small cooler that holds ice water, a pump which cycles the water through a hose to a pad that is placed over the surgical area. The point is to remove the heat generated by the inflammation. Not only does it provide comfort but it helps with circulation, and swelling.

So on the night in question I set myself up for what is hopefully going to be a good night’s sleep. I have an insulating layer on the knee then the cooling apparatus then several elastic wraps holding everything in place.

Soon I am in a horrible dream, fighting for my life against a huge boa (snake!). I am thrashing around trying to pull its coils off my body. However every time I grab it I feel it to be ice cold and can’t hold on to it. It is an Ice Boa! a rarely found subspecies of the snake. In my dream I think how odd it is that the snake is so cold but I am more distressed by how I am unable to remove its coils.

Of course I wake up fighting with the cold hose from the cooling machine with my foot and hands trying to rip the thing off.

It took almost half an hour to recover from the fright. But the strange interpretation that my sleeping brain gave to normal things lives on. I have enough distance from it a week later to see the humor. But I wish the surgery associated nightmares would end.

night of anxiety

I am waiting to lay down for an attempt at sleep. Tomorrow morning at 5.30 i will arrive at the local hospital and get ready for an appointment with a bone saw. Fortunately for me, the saw will be used by a skilled surgeon. When i wake up, part of my knee will have been removed and some high tech metal and plastic will be inserted in its place.

I will wake up numb from my waist down thanks to a spinal block and probably not too groggy from the twilight anesthesia. Most traumatizing to me will the be the role change from provider to patient. Then the therapy will begin. I abhor that this is necessary. It makes me feel vulnerable, dependent, and possibly even human. That last one is rather strange to me, and I don’t mean human as opposed to god like, but human as used in the terms (human error, or we are only human after all). if pressed I  might admit to feeling weak, perhaps even of failure. but since i am not being pressed I won’t admit to such things.

I know that I will wake up at 4.45 get a quick shower with the special antimicrobial soap they gave me, dress in loose clothing as instructed, arrive on time  or a bit early as is my habit with my id card and insurance card. I will be pleasant and undoubtedly joke  with the staff until they shut me up with drugs. But inside I will want to pull the iv out, grab my clothes, run for the parking lot, and take off in my wife’s car to the airport, buy a  ticket to which ever flight is leaving right then and keep on going. Wouldn’t that be a hoot, instead of runaway bride it would be runaway doc.

I have never cared for alcohol in any form, preferring to eat my calories rather than drink them, and now would not be a good time to start, but I can begin to see the appeal of shutting the brain from thinking too much. it is late and I need to go to bed.

D.

Lack of Focus

This man in his late 50’s came in the other day for two small problems. Both of them rather trivial; not so trivial that they did not require attention but trivial compared to what I discovered.

During the visit I noticed a lump/mass/tumor in his neck below and slightly anterior to the ear. “Oh yes, that has been there for months! But it is nothing, see I can push and poke on it and it doesn’t hurt”

“Oh my” how do i tell him that lack of pain is a bad sign not a good one, and that three months is not a good sign either.

He goes further, “and the other reason I don’t worry about it is because it is not just a little lump but actually I can feel it way back here below the ear and all the way to the jaw bone.”

“double Oh my” another bad sign.

The sense of touch is amazing, we can detect the slightest contour, the slightest subtlety in hardness. there are clinical words for these things. If you have a ‘bad’ lymph node the term you don’t want to hear is ‘rubbery’, another word you don’t want to hear is hard, irregular, fixed in place. His was definitely rubbery, irregular and fixed in place. The other thing you don’t want to hear is large and his was large.

So now i have a late middle age, smoker, who is full denial of the seriousness of his problem. All through the visit he kept trying to steer me to the reasons he came in (actually I forget what they were for my focus became rather narrowly focused at the time)

On careful palpation I noticed that the tumor was pulsating. Clearly it was near the carotid artery and it could just be that it was transmitting the normal pulses but it was more than that, it was inseparable from the carotid as if it had enveloped it. For a second i worried (hoped?) he might have an aneurism or something serious but non malignant . However the mass was hard not the soft feel of a large vessel, even a calcified one.

It took some effort to keep the patient focused on this issue. I first of all had to deal with his two minor issues, then insist that he get a soft tissue CT of his neck right away. I consulted with a surgeon to discuss the best approach to diagnosing this mass and depending on what the initial test shows we will either go directly for the biopsy by either a surgeon or interventionist Radiologist, or get a contrast MRI. Without tissue we cannot make a definitive diagnosis and therefore cannot give a prognosis. Although there remains the possibility that it is an odd, non malignant growth it is not likely and  but even then it would cause interference problems. Another worry is that the tumor could erode the wall of the carotid artery, which to say the least, is not a good thing.

Now we just have to check up on him to make sure he gets the test. Then somehow break through his lack of focus regarding the seriousness of this problem.

Ideally i would simply call a family member to guide him through the process, but the only legal way to do that is to have him come in with someone and discuss it together. I cannot reveal his information without his permission stated or implied. (which, by the way, is the way it should be–IMHO)

Learning from the young

I just had my second root canal in two weeks. The first one was an endurance event with four roots. The significance was the skill of the endodontist at administering the lidocaine nerve block. He used a very small needle, made a gentle initial insertion with tiny bits of novocaine, then waited for that to take effect before giving the rest. Nearly painless.

From the start I worked hard at accomplishing what he does and indeed I generally am able to succeed, however… it became obvious to me that I have slacked off and have relapsed into a habit of being quick. But the experience these last two appointments was so pleasant that I will once again start over to see if I can reach the level of skill this young dentist has accomplished.

While speaking of fossils

Just over 26 years ago I was fresh out of Residency, ready to start my new practice, full of an arrogance to which only youth can do justice. In my defense it was not a personal arrogance but more of a training arrogance. I had just completed 7 grueling years of training (post grad school) in which I worked up to 100 weeks and the amount of material I knew was phenomenal.
So when I was introduced to one of the more established Family Doctors in the area, who had been part of the vanguard that established Family Practice as a Specialty of its own, I remember thinking how nice and laid back he was, but also how much of a fossil he was. How could someone that old have kept up all these years; with the massive amounts of evolving medical knowledge and technology?
So, just the other day I was reviewing a resume of an applicant for a receptionist position and it mentioned that she had worked for this old MD.
And it hit me, I am at this point the same age as he was when I thought him a fossil!
Actually, I looked him up and it turns out I am four years older than he was at the time.
So that is what young, newly minted docs think of me now.–Wow.
Karma waited a quarter century to send that thought boomeranging back to me.
I told my office manager that she could call me Dyno from now on, in an effort to keep me a bit more grounded.

laughter a multi-pronged tool

I will admit that I not only love to laugh, I particularlly love making others laugh. Specially a deep, gut, unexpected laugh. And its value in creating a good doctor patient atmosphere would be hard to overstate. However, unbeknownst to most of my patients is the  many other uses to which I put such a common human reaction. 1. humor is complicated, it requires the brain to make unexpected associations and in many cases to keep several items in memory. In this way I find it useful to determine how a patient’s brain is functioning; usually in the evaluation of dementia, depression but also post concussion and severe illness. 2. It requires lots of air to laugh which makes this very useful in my younger patients, say 2 or 3 years of age. they won’t take a deep breath on command with a stethoscope on their backs but get them giggling or laughing and you can hear how they are breathing. Going forward I find that children are not as scared of coming back if they expect ‘the silly doctor’ to interact with them. 3. If you are depressed, particularly significantly so, or if you are feeling quite miserable it takes too much energy to laugh, although by looking at their face I can tell if they ‘got’ the humor. It helps me sort out who is hurting much more than they are saying and also the opposite. 4. it is a huge distraction from whatever the current complaint is and timed appropriately it allows me to examine a joint, or belly or lump without them anticipating pain, or in other cases from amplifying the pain. 5. It makes the time that we spend together more pleasant and perceived as longer or at least as more connected (IMHO) and further compensates for any waiting time they had. 6. It softens patients perception of me in my role as a doctor with all that comes implied with that. Makes me much more approachable by both adults, elderly and as mentioned above, children. Approachableness is hard to overestimate, it allows for a much better interaction, better data collection, better patient recollection, and more willingness in the patient to remember and follow directions.

To be a Hero

I tell students and young providers that one of the greatest things about being in Family Medicine is that one gets to be a ‘hero’ on a daily basis.
I don’t mean ‘hero’ like: running into a burning building and rescuing a kitten-hero, but more like: significantly improving peoples daily lives-hero.
Sure, occasionally we can catch a deadly issue in time to prevent something, but more often it is convincing someone to pay attention to their diabetes, or to try an antidepressant, to give them ‘permission’ to put their health above their work, or to create an atmosphere where they patient feels comfortable enough to tell you the truth.
We occupy a place of trust and it is an amazing opportunity that sometimes I forget because it is all I know. I get to see a side of people that is not shown to others. Most of the time it is a very endearing side, occasionally a dark side, either way they allow me in to their worlds and in many cases be a minor hero in their lives.
On days that I am particularly stressed, tired, frustrated. I try reminding myself of the privilege that is given me on an hourly basis. It nearly always perks me up.

Surgery awaits

It has been a quarter century since I severely injured my knee during a soccer game and it will no longer be put off. Despite a significant amount of weight loss the knee is now worn out and has been impeding my exercise; now it is getting in the way of some of my daily activities. So I am now in the role of patient awaiting surgery.

It is a remarkably uncomfortable role and I find myself second guessing my decision to have a knee replacement. By all logic i have let it go far too long but I keep wondering whether I could/should put up with the pain and instability another year. I find this patient perspective rather educational. I am not worried about a poor outcome, or the anesthesia or the recovery; rather a vague fear of being vulnerable and obtusely being absent from work for the such a long time. I have not missed work for more than three weeks since I was a young man, and the prospect of being out for over a month is terrifying. I am not sure whether I am more scared of being bored or of enjoying my time off.

Being in the patient role helps me understand my patients better; there is a lot to be learned by going through the process; thing that i can use when my patients exhibit the same feelings. Nevertheless it is six weeks until the knife and I find myself conveniently ‘forgetting’ it is looming on the horizon.

Then there are the multitude of logistical issues to handle: informing patients I will be out for a month, setting up a system to run the office while I am away, making sure that patients have sufficient refills on medicines, reassuring patients that the covering doctors are just as capable, etc.

New Record!

For the last ten years or so the all time record for amount of alcohol consumed by one of my patients (at least what they admit to) has steadfastly remained at one case or beer a day. No, I did not have the presence of mind to ask which beer; I presumed it would be the cheapest available because we are not talking pocket change, we are talking luxury car payment money!
Last month a patient had a rather unfortunate reaction to a very common and benign medicine probably due to the unknown amount of alcohol he has consumed for the better part of his 50 years. To his credit he has not had a drink in over a week ( since his health issues reached a crisis) and he quit tobacco two months ago so he has the commitment to pull this amazing twofer off.
However, he admitted to drinking a gallon of Wild Turkey over a weekend on a regular basis. That is 128 shots of whiskey! the calories alone (9000) are off the chart. I do not know how much he drank during the work week but either way he blew away the previous record.
Considering my age I do not expect this to be surpassed.
How he remains at a healthy weight is beyond my understanding. I have to watch every morsel that goes into my mouth, exercise for an hour a day simply not to regain any weight.
Lucky for him the recuperative powers of the liver are astronomical and if he is able to abstain, he may well have a good prognosis.