Endless

The older I get, the faster time moves. Except for the last 2 1/2 weeks. Time now crawls. I'm bored and restless, but also unable to concentrate on anything for more than a few minutes. I've been reading, watching Dr. Who (halfway through season 2), watching NCIS, praying, trying to read scripture.

The first week wasn't too bad. I was doped up enough to sleep a lot. About 10 days ago, I woke up. I don't need pain medicine much anymore, which is a great thing, but I'm also awake, alert, and bored out of my skull.

I think that my favorite books, the Twilight series, have spoiled me. I can't find much else to read. Before you all gag, let me tell you why it spoiled me. I used to read mysteries, thrillers, sci-fi, historical novels, etc. Blood and gore didn't bother me. Violence could be troublesome but I could "read around" it. Romance novels never did much for me. After reading Twilight I started reading fantasy, but much of it is not well written. The novels are well written, clean, and for me they tell the stories of good vs evil, making choices, and forbidden love.

For some reason, I cannot stomach the mysteries that are out these days. I've tried the Stephanie Plum series and couldn't get through the first novel. I love Sue Grafton but she only turns out a book every couple of years. I've read the three Stiig Larrsen books already. Patricia Cornwell has become too violent. And too soupy, at the same time. I tried reading "Extremely Loud and Incredibly Close" but it has two no-nos: a sad little kid and 9/11. I don't like horror novels. I tend to dream whatever I'm reading about and I don't want nightmares. I'm not interested in a twenty-something angst-ridden young man or woman's journey to find themselves as they visit every Starbucks on the east coast.The Help? Read it. Loved it, except for the end.

I don't know what to read anymore!!!!!!! And I hate it because I love to read! I want to get lost in a book, I want to get so deep in that when I finish the book, I feel lost. I want to see the characters in my head as I read about them, and miss them when I'm done.

I've tried re-reading some of my old favorites. They don't hold my interest. i want to read substance but can't concentrate, probably because I'm not comfortable. I'm not in pain, I'm just not comfortable. Having to prop this leg up is a real pain, in my lower back, my right shoulder, and my neck.

Time is also endless because I'm not sleeping. I cannot sleep on my back. I never have been able to sleep on my back. My right shoulder is getting tired of my sleeping on it, but I can't sleep on my left side because the cast is on my left lower leg and I can't prop it up if I lay on my left side. To add more gunk to the murk, my CPAP issues continue. The most recent mask fits my face and doesn't leak but it has a ridiculous outflow system. All CPAP masks have an outflow system to handle the exhale, and most masks blow the air out in a straight line, either up, down, or forward. This mask blows it out in a circle, the idea being that it will be more diffuse and it won't blow on you or your partner. Not so. And when I lay on my side, it blows down into the pillow, sounding like a gale-force wind is blowing through my room. I manage to fall asleep after awhile, but by then I've tortured my neck and back, trying to find a position that will elevate my leg and keep the mask from blowing into the pillow. I tried sleeping on my back and discovered that with a measurement of 19 cms, outflow cannot be diffuse, and therefore cannot be quiet.

My doctor won't give me a sleeping pill. I have to wait for the CPAP company to visit my house and bring me more masks to try. If I sleep without it I wake up with a sore throat because my pharynx is no longer used to the effects of snoring. And I need the CPAP not so much for the snoring, but because I literally stop breathing for up to 30 seconds at a time while sleeping. I need the CPAP.

So. Not sleeping well. Not able to concentrate. Easily bored. Uncomfortable. Feeling guilty for putting my most wonderful husband through this.

Class begins again for me on January 9th and I hope that will mark a turning point. I'm also signed up to take a free internet course on Natural Language Processing, which starts a couple of weeks after that.

12 weeks of NWB should be ended by March 7th. My six weeks of enforced elevation will be done on January 25th. My medical leave is scheduled for 3 months and I have disability until mid-February. If I can manage it, I hope I can get back to work and get my brain rebooted.......

Customer Service, Part 2

You might think it odd that I return to this topic on Christmas evening, but there's only so much reading/TV/Angry Birds that a person can do and still be entertained.

When I left off last week, I was discussing how hospitals place great store in customer service, and in fact they tie quality of care to customer service. I for one disagree; I have worked in the healthcare industry for 25+ years and it seems to me that the more they focus on customer service, the worse the quality of care.

Anyway, I left off with my recovery room experience. I was in recover 2 hours longer than necessary because a bed was not yet available on the orthopedic floor. By the time I left recovery, I was pretzeled up from the uncomfortable gurney and sick of being blind. Remember, no glasses. When I got to the ortho floor, I saw sign after sign saying that discharge time was 11 AM. Good, I thought. Having worked for the director of case management, I was glad to see that the discharge process was receiving such attention. If I hadn't been full of narcotics, I might have remembered that I sat in recovery because I didn't have a bed....

And the bed. As bad as the gurney was, the bed was almost worse. It was merely an air mattress on top of a bed frame. No regular mattress. No trapeze (a device that hangs above your head and allows you to pull yourself up in bed; a must for any ortho floor). At least 3 different people noted that I had the "wrong bed" but nothing was done to change it. The bed caused so much back pain that I required pain meds FOR MY BACK, NOT MY ANKLE.

A bright spot in customer service was the swift action of the Acute Pain Service, who responded quickly when my nerve block catheter became kinked or blocked. And I have to say that the nurses were pretty decent. The last time I was on the ortho floor the nurses complained constantly about any and everything. I was spared that this time.

You know, it's the little things that matter, because they add up over time. I had to use a bedpan pretty frequently and that was most difficult without the trapeze. The 3-11 nurse ordered a bedside commode for me at 3:30 PM. It didn't show up until well into the night shift, and the only reason I even got it is because I asked if it had come up yet- turns out it had been sitting in the hall for awhile but no one knew where it was supposed to go. It would have been nice to be spared 4 bed changes that resulted from trying to use a bedpan on an air mattress, without a trapeze.

The discharge process was...words fail me. The ortho chief resident popped in at 6 AM (turned on bright lights and asked me to wiggle my toes) and said that my discharge orders were written and prescriptions were in my chart. I had to go to PT to prove that I could manage a walker, but other than that and some paperwork, I could have been discharged by the golden hour of 11 AM. Instead, because no one talked to each other and because the discharge nurse (whose sole job is to prepare discharges) was having a "bad day," I was not discharged until 2 PM. AND....they sent Ken down to bring the car around but didn't manage to call escort and get me to the front door until 2:35. I am assuming some other poor patient was hanging out in recovery waiting for my bed, while I was sitting there waiting for the process to let me go!

If I were to grade hospital stays based on customer service, this admission overall gets a C. The acute pain service gets an A, the discharge process gets an F, and the nursing staff get a B. The focus on treating pain is one that I vigorously applaud, but some of my pain was due to their crappy beds. In fact, except for when the nerve block hiccuped, I had no pain in my ankle at all. I had lots of back pain from the beds and muscle pain from having to haul myself around the bed without a trapeze.

The nurses at AGH are unionized and no one had more than six patients for their assignment. The discharge nurse should walk onto the floor and start filling out discharge paperwork ASAP. My nurses were mostly very kind, very nice people but my day nurse was 2 hours behind with meds and with facilitating my discharge.

I was very pleased to receive my Press-Ganey survey in the mail....

Did Not See That One Coming

I went for my first post-op follow up on December 22, which also happened to be the five year anniversary of breaking my ankle. I went in with certain expectations and had them all pretty much blown away.

First of all, my original break and surgery left me with two 2-inch screws in the medial mallelous (the big bump on the inside of the ankle), a long screw through the two leg bones, a plate on the outer side of the fibula (the skinny bone that runs beside the shin bone and ends with the bump on the outside of the ankle), and nine more screws. Two years later I had the plate and eight screws removed. The hardware removal was my third ankle surgery.

The catalog of scars at this point, November of 2008, was:
A. A long, wide scar on the outside of the ankle.
B. two shorter scars on the inside of the ankle, parallel to each other and one an inch or so above the other.
C. A weird scar near the medial line that was caused by bone going through skin. That was never stitched and it is bumpy and pink.

Fast forward to December 22nd. I had no idea what I would see because none of the surgeons bothered to talk to Ken or me after my surgery (which is rude and poor practice). When the initial bandage came off I was shocked to see a stapled incision in the front of my foot and ankle. The other incision was on the medial side. I was surprised to find the lateral side free of incisions. You see, according to the surgeon's website, the ends of both the fibula and tibia (the bumps on either side of your ankle) would be removed as part of the fusion procedure; clearly my fibula was intact. And the whole thing looked ugly and deformed between the swelling, bruising, and anatomical changes.

Next shocker was the x-ray. I have 2 of my original screws (they broke off in the fibula and were left there), and the two medial screws were gone. BUT i now have seven screws and a plate in the area of the fusion. I was expecting three or four screws tops. Now I'm worried about eventual pain from that plate.

Next up was the visit with the PA who said that my joint was significantly arthritic and that I must have a really high pain threshold. Not really- I just didn't have much choice......

On to the application of my very first complete cast. I've had two partial casts and a boot but never a full cast. It is lined with stockinette but the edges are really sharp and I can really feel it when I bend my knee up to use the knee walker. I have three weeks in this and lurking beneath are all those staples which will come out when this cast comes off. They should be nicely grown into my skin by then. I think there are 25-30 between the two incisions.

I was really shaken up by all of this, which surprised me because you would think that by now, nothing about this ankle should surprise me.

Customer Service

Customer service is a big buzz phrase in any industry today, and especially in health care. Health care organizations spend buckets of money on patient and staff satisfaction surveys (check PressGaney.com). HCOs also spend millions on advertising, explaining their amenities and explaining why you will be so much more comfortable in their hospital. I think the best way for someone to learn about customer service is to experience it first hand.

Have you ever seen Undercover Boss? A CEO of a large company goes undercover, working in various parts of his own company to find out what it's like to be a "little man" at that company. I suggest that a couple of hospital CEOs do the same thing. In a hospital as large as, say, Allegheny General (AGH) or one of UPMC's sprawling facilities, a high-level exec could easily play patient because the majority of the staff do not know who they are.

I would especially like to suggest that some high-level desk jockey at AGH become an undercover patient. I have had 3 overnight-stay admissions to AGH; in 1998 I had elective back surgery and spent one night, in 2006 I had my ankle injury and spent 3 days recovering from the open reduction internal fixation and other effects of the fall, and finally, just a few days ago, I spent one night after an elective ankle fusion. My first experience was okay. Not bad, not good. It was 13 years ago, when hospitals appeared to care more about keeping their doors open. The care was indifferent but adequate.

My 2006 experience was dreadful. From the ER to the front door at discharge I received substandard or dangerous care from the nursing and ancillary staff. The only bright spot was the orthopedic physicians, who were fabulous. I won't revisit this any further except to say that I got a lot of grief from my boss (I was an employee of the hospital) for speaking out.

This third experience was not all bad. The food was pretty decent, the room was clean, and the escort people managed to keep the elevator door from closing on my elevated, injured leg.

It wasn't all good, either. I started out by arriving at the Ambulatory Surgical Center at 5 AM. I spent 15 minutes or so in the waiting room which was packed wall to wall. Was there a sale on surgery? The ambulatory surgery center process wasn't bad, and at 6 AM I was picked up to go to the OR. I had to give up my glasses, which I absolutely hate because I can't see anything, not even the clock in front of me. I was first rolled into the incorrect pre-op area ("she goes into the nerve block room Ronald!) and then parked at the end of a row in another pre-op area. I was very anxious because I do not like needles, and I knew that this was the place for the IV and the nerve block. Thankfully I did not have to stew for very long; within a few minutes I was literally surrounded by men (too bad I couldn't appreciate them, as blind as I was). One lovely young man picked up my left hand and began to do the slap that is supposed to make the veins show themselves. My veins have always seen past this game and once again refused to make an appearance. Rather than torture me, they decided to insert a small-bore IV now, enough to give me some sedation for the nerve block, and put a larger IV in after I was in the OR. Chalk up one very big check mark for customer service!

I woke up in Recovery, on a very uncomfortable gurney. The pain it caused my back just made all the other pains worse. I was awake and ready to leave recovery by noon but had to wait two hours for a bed. I got to listen (remember I was denied my glasses) to the woman in the next slot scream for dilaudid and scream that her pain,level was a ten....until she was told that she couldn't leave recovery until her pain mwas below three. Hallelujah, a miracle happened because her pain instantly disappeared and she was off to her room.

It was 2 pm before I got out of recovery. I will pick this story up in Part 2.

Target Practice

I have to wonder what goes on once you're asleep in the OR. Do they truck the new anesthesia residents in to practice on sleeping people? Here is why I ask that question.

I was wheeled into OR 22 with three fresh puncture marks. One was from the IV in my left hand. Must give the anesthesia resident a big "atta boy" for getting it on the first try and for using a little local novocaine-like stuff to keep it painless. The next puncture mark was for the continuous sciatic nerve block. That's a story for another blog. The third and last puncture was for a short-acting femoral nerve block on the medial knee.

Once I was on the stiff and unyielding OR table, I was positioned in the usual fashion with arms out on extensions. Leads were attached and I had the O2 mask in place, doing the deep breath thing. Someone behind me dropped a bunch of IV needles and tubing onto my chest and I thought I heard someone say that they wanted a second line with a larger needle. Then came the burning in my left hands as I was anesthtized into la la land.

Skip forward to Wednesday evening, about 15 hours later. I still had the left hand IV and nerve block catheter and had not yet remembered about the second IV. The nerve block cath developed a kink and required the STAT presence of the Acute Pain Service resident who was on call. While he was doing his thing I was all the way over on my right side, clutching the side rail with my right hand. That's when I got my first good look at "Target Practice Arm."

The back of my hand was a massive purple bruise. I counted 5 puncture marks along the main vein. The inside of my right wrist is also bruised with one puncture mark. And lastly, halfway up my inner right arm was a deep blue bruise with a central puncture.

I'm glad I was asleep for all of that. Apparently the resident who put in the original IV noted that I had skinny, rolling veins amd that it might be difficult to start with a large bore needle, so he opted to start with a 22G and wait until the OR to insert the 18G which is larger in width and allows for more rapid fluid administration. Can I say amen and thank you? If I had been awake for seven failed attempts I might have lost my mind!!!!!!

Stay tuned for the story of Dr. Orzo, pain doc extraordinaire. I think I might call that one the Twitch Test.

Wow, it's harder when you're five years older.

As many of you know, I fell down the stairs five years ago and shattered my left ankle. For those in the biz, it was a bimalleolar fracture with severe syndesmotic disruption, which means that in addition to breaking the ankle, I dislocated it. After five years, the repaired joint had deteriorated so that I could no longer walk without pain and sometimes the ankle would give out completely. I spent 4 months waiting to see THE ankle man of Pittsburgh, Dr. Stephen Conti, and then another 6 weeks to get onto his surgical schedule. I spent that six weeks preparing, having already been through the joys of non-weightbearing and all its limitations five years ago.

We live in a ranch house now, and I was certain that that would make this process simpler, and it has. And instead of hopping around with a wheeled walker, I have a fabulous knee scooter. It's much easier on the body and kinda fun, too.

The next fabulous invention is the cast cover for the shower. Gone are the days of taping a plastic bag to the casted limb (which always leaked to some degree). Today I am using the Duro-med cast cover, an ingenious device with a tight rubber collar and heavy plastic bag for the limb. They are available in long and short, for legs and for arms. I've used it twice so far and my leg has stayed completely dry. There are other types, too, that are disposable, but this is the one recommended by my physician and I went with it.

And of course my toes are hanging out and getting cold. No worries! Welcome the Cast Cozy (available in heavy or light weight). It velcroes right around the foot and keeps your toes toasty

I applaud the wonderful people who made these products!

The surgical experience was also made better by technology. The historic process was to stuff you full of pain meds in the hope that you would not care that your ankle felt as if it were resting under a fully-loaded Mac truck tire. Five years ago I spent 24 hours in a dilaudid-induced haze with pain so intense that I actually had nightmares about it. Narcotics are also bad for those of us with sleep apnea, and they can mess up the intestines, too. The newer thinking makes a lot of sense- insert a skinny, skinny catheter into the area of the main nerve and send a continuous infusion of long-acting local anesthetic to bathe the nerve. It's called a continuous sciatic nerve block and it is amazing. I found out just how amazing it was on Wednesday evening when it either kinked or blocked and stopped working. I was a sweaty, crying, screaming mess. Kudos to the anesthesia resident (from the Acute Pain Service) who managed to unkink it and gave me a huge bolus before hooking it back up.

The medication is contained in a balloon, inside a rubber ball, and it slowly squeezes down until the medication runs out or your doctor has you remove the catheter. Yes, I said, has YOU remove the catheter. Or in my case, it was Ken, who really manned up and took it out on Friday, after it had been in for 48 hours. And once it wore off, I was okay. I had started on some good narcotics and they were on board when the pain kicked in, and it was very tolerable. The ball is called a Q-ball, and you wear it in a little bag around your neck (to keep track. And you become very paranoid about that catheter). You had to see us all lined up in physical therapy with our Q-balls hanging around our necks!

I plan to blog some more about this whole experience. It certainly is better doing this electively rather than traumatically! So stay tuned and I will try not to be too gross as I describe my experience.