Getting Back On Track, Again

A kind soul on Facebook finally gave kick in the seat of my pants that I needed to get this blog going again. Let's see, where were we...ah, yes! The nightmare during surgery.

I've been trying to figure out that dream for a couple of years now, but a description still eludes me. Suffice it to say that I dreamt, either during surgery or in recovery, that I was being operated on in a wood-paneled room in something that seemed like a room in, of all places, Hell!. I can't remember if I was in hell, going there, or if World War III had just broken out and everybody was headed there. Either way, I dreamt that I was trying to warn the surgeon (in mid-operation) that he shouldn't be operating on me with the end of the world imminent.

My wife says I really did say this next part during recovery. Apparently, I told a nurse that I had accidentally created a MIDI controller (musical device for non-techheads) that would launch all of the world's missiles if someone programmed it to play a certain song. Don't ask me what the song was - I can't remember.

The whole hallucination was probably due to the length of the operation. I was under for two or three hours. Not long when compared to an organ replacement, but plenty long when you consider just how much ankle hardware the doctor had to insert in order to repair bimalleolar fractures with complete dislocation on both feet.

Suffice it to say that I was under for more time than I've ever been. I also woke up in EXTREME pain.

Not to end the story, but just a quick status update: I'm now on long term disability leave from my job due to a laundry list of problems that keeps getting longer. I have a heart condition called PVC (Premature Ventricular Contractions) that can strike without warning, and the electrocardiology specialist who verified these (along with another heart problem) says there's nothing he can do, mainly due to the operation I had which put the Greenfield mesh filter into my vena cava. I won't go into the other problems since they're most likely not due to the gastric bypass, but next update I will go into the real hell that is called Spending Time in a Crappy Hospital.

Watch this space for the next installment, and thank you for reading.

But First...

I'm still having some problems getting my thoughts sorted out on the nightmare mentioned in the previous post; just thinking about it brings up some degree of post-traumatic stress. So, until I can deal with those demons, I figured I would put this online for your perusal.

What follows is the text of the Operation Report from December 17th, 2009, the day on which my ankles were fixed. I just received this after asking for a copy of it during a follow-up appointment I had on Tuesday. Certain portions have been omitted to keep swarms of lawyers from descending on my family. Also, a few reformats have been done here and there to make it more readable, and I've added a few explanations of some of the more technical terms, trying to limit those so that I don't defeat the goal of improving readability.

Here we go:

OPERATION: 12/17/09

PREOPERATIVE DIAGNOSIS:
1. Left bimalleolar ankle fracture.
2. Right bimalleolar ankle fracture.

POSTOPERATIVE DIAGNOSIS:
1. Left bimalleolar ankle fracture.
2. Right bimalleolar ankle fracture.

OPERATION:
1. Open reduction internal fixation (a.k.a. ORIF - fixing a fracture after incision into the break site - ed.), left bimalleolar ankle fracture.
2. Open reduction internal fixation, right bimalleolar ankle fracture.

ANESTHESIA:
General.

ESTIMATED BLOOD LOSS:
50.

COMPLICATIONS:
None.

DRAINS:
None.

TOURNIQUET TIME:
Left 25 minutes and right 27 minutes.

INDICATIONS FOR PROCEDURE:
The patient is a 46-year-old male who suffered significant bilateral ankle fractures after a fall 5 days prior. He was eventually medically cleared and due to the displaced subluxed (dislocated - ed.) ankle fractures bilaterally was indicated for ORIF. He understands risks and benefits of surgery and consents for the procedure.

SUMMARY OF OPERATION:
Following successful induction of general anesthetic, both ankles were prepped simultaneously. Ancef 1 g (an antibiotic - ed.) was administered prior to start. Calf tourniquets were applied. The left side was done first.

Following exsanguination (I assume this means either free bleeding or some removal of blood from the site - ed.), toruniquet was inflated on the left. Lateral incision was made through skin and subcutaneous tissue. The fibula was dissected down to and underwent reduction. There was minimal comminution (breakage into a number of pieces - ed.) but somewhat softened bone.

Fracture site was irrigated of hematoma and a curette was used to remove any loose bony fragments. It was then reduced anatomically with a bone-holding clamp, and a single compession screw AP (anterior/posterior - ed.) was placed to hold the reduction. A 6-hole 1/3 tubular locking plate was bent to conform and placed along the lateral aspect. Initially, 2 compression screws, cancellous (i.e., into spongy bone material - ed.) was placed distally (at the far point - ed.) and cortical (dense bone - ed.) placed proximally, followed by 3 locking screws of appropriate length.

We then moved to the medial side and made a small curvilinear incision over the medial malleolus. Opened the deltoid ligament to identify the fracture, irrigated it, and reduced it anatomically and held in place with a bone clamp. Two 50 mm 3.5 partially threaded screws were then placed in parallel through the medial malleolus obtaining good compresion and good derotation (stability - ed.).

X-rays confirmed good hardware placement and anatomic ankle mortise reduction on AP and lateral images. The limb was then wrapped snugly with an Ace wrap and the tourniquet deflated.

We moved to the right side and performed a similar procedure after tourniquet inflation; first the fibula and then the medial malleolus in similar fashion. We used a 7-hole 1/3 tubular locking plate laterally with a single AP compression screw for this similar short oblique fracture. Anatomic reduction was achieved on both sides. Final X-rays confirmed good hardware placement, screw length, and mortise reduction.

Both ankles were then irrigated thoroughly and closed with 0 Vicryl (absorbable sutures - ed.) for the deeper tissues including the deltoid ligaments medially followed by 2-0 Vicryl for the subcutaneous tissue. The wounds were then dried, Mastisol (an adhesive - ed.) and Steri-Strips were applied to all 4 incisions, Xeroform (gauze - ed.) and sterile dressings followed by a soft roll and boots placed bilaterally.

The patient was then reversed from general anesthesia and taken to recovery in stable condition.

The aforementioned nightmare happened either during the operation or during recovery. I'll never be sure which, but from what my wife tells me I'm guessing it happened in recovery.

I promise it'll be up soon. It scared me, but it might give you a good laugh once you've read it. Go ahead, if you can't laugh at the walking wounded, who can you laugh at? (Hawkeye Pierce, M.A.S.H., if memory serves.)

More Omens and More Operations

So, here we are, four days following my re-admission to Hospital X. According to my wife, I've since had several pints of blood transfused, had several more pints of other fluids and nutrients infused, and now have a piece of titanium permanently wedged into a major blood vessel to keep clots from killing me. The internal bleeding appears to have stopped and my blood pressure is up a bit, so I'm finally out of ICU and am being given morphine for the pain. Meanwhile, both my ankles have been somewhat re-set after sustaining both dislocations and multiple fractures and are now wrapped, awaiting an operation to put everything back in its proper place.

Things would appear to be getting better, right? Well, you've probably guessed it - another bad omen popped up earlier in the week, this time involving the doctor scheduled to fix my ankles. He had a death in the family and had to go out of town for the rest of the week, meaning his associate would be performing the surgery. (Someone upstairs apparently took notice and showed a bit of mercy, though, as my employer told my wife on the same day that the company was willing to put me on FMLA leave until I was physically able to return to my job.)

The ankle repair surgery took place Thursday afternoon. It was supposed to last around three hours, but after a four hour wait my wife has still not heard from the surgeon. She says she got someone to call and check on me at that point and was told that I was already on my way back up from the recovery room. The surgeon didn't even bother to stop by and talk to her about the operation. I heard about this from her later on, and she was supremely pissed with the whole situation. Our relationship with this doctor would not improve until much later (after I'd left the hospital, in fact).

Up to this point I'd been going in and out of consciousness and lucidity, thanks to my physical condition and/or whatever drugs or anaesthesia was being used on me at the time. Aside from feeling goofy at times and at other times thinking that I was in Austin instead of Dallas (see the previous update for info on the latter), I hadn't had anything disturb me mentally other than the sheer pain of the situation. Something different happened during the ankle surgery, though - I don't know if it was in the operating room or in recovery - but I had some kind of dream that scared the hell out of me for a while. It was disturbing enough that I apparently felt the need to describe it to the recovery nurses, who then told my wife so that she could have a good laugh at my expense.

I'll describe what I saw in the next update and let you be the judge.

Extremely Silly Walk Not Attempted

As I mentioned, my wife took a photo of my feet while we were in the ER.  The doctors had not yet worked on them in any way when she took that photo.

The photo is NOT FOR THE SQUEAMISH.  It includes an angle that is not normally seen in nature, at least not on the human body.

If you are absolutely certain you wish to see that photo, click here.  It has not been photoshopped at all.  The black spot is from a magic marker and indicates the foot has been injured.  More on this in a moment.

You will note that the left foot doesn't look too bad when compared to the right foot.  That is true, until you consider that it has been snapped off and is now lying at a 90 degree angle to the rest of my leg.  Believe me, it's not supposed to point that direction on its own.

My wife says the doctors and nurses kept walking past the end of the gurney and bumping one foot or the other, not realizing that both had been broken.  They did this several times, and each time she says I would let out a blood-curdling scream of pain.  Eventually, someone got the idea to tie red tape around both of my feet so that everyone would know that both were off limits.  That worked better than nothing.

The worst part about the situation is that the doctors could neither operate to fix my ankles, nor could they give me morphine for the pain.  If you'll remember, my blood pressure was 60/20.  I was bleeding internally, and until they could stop it there was a huge risk that a blood clot would break loose and enter my lungs, killing me.  As a result, all they could do was wrap my feet in gauze, put Fentanyl patches on me, and move me to the Intensive Care Unit so that they could try to find the source of the bleeding.

I don't have much memory of what went on in ICU.  I remember a lot of pain, and I remember a terrible thirst because I couldn't drink anything due to the stomach bleeding.  My wife brought in ice chips made from a zero-calorie fruit drink and slipped them to me when the nurses weren't looking.  I also remember having IV tubes stuck in me several times until the doctors finally decided to give me a PICC line (one line that led toward my heart and had three connectors hanging out of my left arm).  I saw at one point that they were feeding me through the IV, again since they couldn't put a tube into my stomach.

All this while, for some reason I guess I will never understand, I thought I was in Austin.  Don't ask me why.  I just thought Austin was outside, waiting for me once I got better.  There were a lot of other strange things that happened, like me demanding my wife hand me my cell phone so that I could call in sick (my boss asked if I could come in to work in a wheelchair - the doctors nixed that), and me asking the doctor how many days I would be out of work (he said it would be weeks, not days).  Again, my wife says she will not fill me in on the other blank spots in my ICU amnesia.  Based on what I do remember, I guess I should be grateful.

To continue, my wife says they ran all kinds of tests on me while in ICU but never found the source of the bleeding, despite eight different doctors being assigned to me all at once.  Nevertheless, the bleeding stopped on its own after about three days in ICU.  At that point a pulmonologist decided to put something called a Greenfield Filter in my vena cava.  The filter is essentially a titanium mesh umbrella which is designed to catch and stop clots headed to my lungs. (I still have that filter implanted in me.)  Once the filter was in, the doctors were finally able to operate on my ankles, and I was able to begin a whole new series of hospital nightmares.

Stay tuned.  The ankle operation was anything but routine.

Triage Two-Step

At some point on Sunday, just one day after being released from Hospital X, I returned to Hospital X's emergency room entrance. My wife quickly procured a wheelchair and either wheeled me inside or had me wheeled inside; I'm not quite sure which. In either case, my job from that point on was simply to sit in the wheelchair, hold onto my walking cane, and wait to be called back for triage.

Around 30 minutes passed, according to my wife, and I had yet to be seen by any of the ER staff. I realized at that point that I was going to have to use the restroom if the wait stretched out any longer, so my wife wheeled me over to the nearest one. The bathrooms near the ER at Hospital X are of the unisex one-person-at-a-time type, and I learned by trying to open the door that the one I wound up at was in use and its door was locked at the time.

I remember my wife saying, "It's locked," followed by the sensation that she had moved me slightly away from the door. For some reason that I do *not* remember, I felt the need to get out of the wheelchair and try the door handle again. I stood up with the help of my walking cane, determined once more that the door really was locked, and then turned away with the intent to move out of the path of the current restroom occupant once they were finished with their business.

Now, if you've ever experienced the sensation of blacking out while still being aware of things that area going on, you might partially understand how I felt in the seconds that followed. However, you'd also have to understand what a tree probably feels and hears when two of its major branches break off in order to fully comprehend how I felt. In any case, my vision suddenly went to black and I had a sensation of falling, accompanied by the *feeling* of a snapping, cracking sound moving through my body to my ears.

The next thing I remember is being on the ground and hearing my wife gasp in horror:

"Oh my god! His ankle's broken!"

Close, but not exactly right. Both of my ankles were broken.

I had apparently slumped against a wall behind me and fell, just like a tree, to my left. As I fell, both ankles snapped as if my shoes had been glued to the floor. Unfortunately, neither my wife nor anyone else saw exactly what caused me to fall, so no one really knows if I passed out and fell on my own or was knocked over by the man and his 4-year-or-so-old daughter who had exited the bathroom as I was turning away.

I passed out before I could hear my wife yell at the man to hurry and get help. I regained consciousness only long enough to hear a nurse call, "Rapid response to ER...Rapid Response to ER," over the hospital intercom, then blacked out again until someone started moving me around. I remember knowing that I was in intense pain at the time, but my mind had disconnected itself from the sensation to the point where I don't remember what the pain felt like. My wife tells me that I'm lucky on this point.

During another brief moment of consciousness, I recall being moved onto a body board. I also remember someone cutting off my pants so that they could get to my legs for an examination. I somehow gathered up enough brainpower to crack a joke about needing to go shopping for new pants again, since they were cutting off a pair I'd just purchased a few days earlier.

The last sequence of events I remember in the hallway began with a nurse telling a doctor that my blood pressure was 60 over 20. Normal blood pressure is usually near 120 over 70, so 60/20 meant I was losing blood, and losing it badly somewhere. The doctor got her to re-check, and she still came up with 60/20. He thought for a second and then flew into action, ordering up IVs of fluids and blood.  When the nurse asked what flow rate she should use, he told her to "flood" me since I was obviously running several pints low.

I have no memory of what happened from this point until I woke up in the Intensive Care Unit. Again, my wife tells me I'm lucky and that she has no intention of refreshing my memory on the matter. She *did* take a photo of my badly broken ankles while in the ER, though. When a nurse asked her why she did that, she said that I would want to see what they looked like.

Damned right. Anything that would cause as much trouble as they would absolutely required documentation.

Bloody Confusing

I've had several operations/procedures done on me in the past that were either outpatient or involved single-day hospital stays. Every one of them has given me trouble in the days following the procedure. As I mentioned earlier, I have problems with some sedatives and anaesthetics surpressing my breathing reflex, and on occasion the effect has lasted for days after the procedure. (Try sleeping when you have to consciously remind yourself to breathe at times - that's what it's like.)

Other procedures have left me feeling like I've been buried under a pile of a dozen wet blankets. I have a hard time staying awake for any length of time and can't get up, turn over, or do any kind of moving easily. At least I don't have to concentrate on breathing when facing this type of post-op discomfort.

The gastric bypass left me feeling closer to the dozen wet blanket side of things, but without the problems of being unable to get up or move. I had trouble waking up, but when I did attain consciousness, I could get up and move around if I needed to do so.  After I had gotten over the problem with the lemon-flavored pain medicine (see previous update), I was actually pleasantly surprised with the degree of mobility I had.

(Note:  Here comes the part I warned you about at the end of the last update.  Skip to the next update unless you want the dirty details, which are provided in generous quantity below.)

One other particular problem I've had with gastrointestinal procedures is post-op constipation. Sometimes it's taken me a week after surgery before I have been able to have a bowel movement. At worst it's taken almost three weeks, as was the case when my appendix was removed back in 1983.  It's never a comfortable affair, regardless of the duration, and finally passing a stool can be more painful than the period of constipation had been.

Things were very different this time. I actually needed to go to the bathroom, not too long after arriving home. I remember being rather surprised that I was actually able to have a bowel movememtn so soon after having a major gastric operation. However, I also remember having a hard time staying awake while sitting on the toilet. I did nod off a few times, but I always caught myself before suffering the humiliation of falling off the throne in mid-dump.

I had several bowel movements between Saturday evening and Sunday and continued to be somewhat surprised that I was going.  However, in retrospect I should have instead been worried about what was happening inside of me.  Each movement involved black, tarry stools, something I'd never experienced before but had certainly heard of. Black, tarry stools mean that blood is coming out of one's body by way of the intestines, but since I'd just had a major stomach operation I figured I was just passing blood that had entered my GI tract during surgery. My wife thought the same, but at the same time she was concerned about a "funny smell" (her words) that hung around after each bowel movement despite the best efforts of the bathroom vent fan to clear the air.

My wife tells me she started getting really concerned towards Sunday noon when she began having more and more trouble getting me to wake up for pain medicine doses and other things like eating popsicles and so on. As mentioned earlier, I'd had problems waking up in after surgery in the past and wasn't very concerned about this myself, but my wife said this time was worse that any she'd dealt with during my previous recoveries. She says the situation eventually got so bad that she decided to call the surgeon's office (I don't honestly know if she talked to a nurse or the doctor himself) and tell them that she was having trouble waking me up. She told them that I was "lethargic and unresponsive," and expressed her concerns about the "funny smell" after bowel movements to them.  She says the person on the other end of the phone didn't seem very worried and didn't even give a "hmmm..." to the funny smell issue.

The doctor's office gave her two options: either bring me in to the office on Monday, or take me to the Emergency Room now if she thought I was really that bad off. She chose the latter. Again in retrospect, if she'd waited until Monday you'd probably be reading an obituary instead of this blog, so despite what happened later that day in the ER, her actions likely saved my life.
 
(To be continued...)

Trouble In Stealth Mode

One uneventful trip home later and I'm sitting on our sofa with my right side pretty much propped up by the arm cushion and my head leaning back with my face pointed at the ceiling. I'm feeling very groggy and am occasionally falling asleep sitting up. No serious nausea, though, and fortunately no apparent problems with my breathing reflex.

My wife left to get my pain medicine prescription filled, which turned out to be a much more difficult task than you would imagine (partly my fault). The scrip was for hydrocodone elixir (i.e., liquid), so I asked her if she'd get the pharmacist to put a flavor in it to help it go down a bit easier. I was thinking grape or cherry, but I didn't have the wits about me to mention either of these. In short, I left the flavor choice up to her, and for some unknown reason she decided that lemon would be good for a person who has just had his stomach rearranged. So, she asked for and brought home lemon-flavored hydrocodone.

Note: Pain medicine isn't intended to *cause* pain.

The dose she gave me went down my throat for the most part, but a bit of it backwashed and tried to climb up into my sinuses. Neither direction handled things very well - think having a blowtorch fired at your uvula. One coughing fit later, I told her in a voice flavored with misery that there was no way I'd be able to take any more doses of the mixture she'd brought home. She huffed and did her best to keep me from realizing she was pissed at me, and then set out to trade the lemon-flavored lava for regular hydrocodone elixir, no incendiary flavor added.

She went back to the pharmacy that filled the scrip, only to find that it closed early because it was a Saturday. She did eventually get the prescription swapped, but only after driving 30 minutes to the only 24-hour branch of that particular pharmacy and doing god knows how much pleading to get them to transfer the prescription and reissue it in its normal nasty-tasting state. I have no idea exactly how long this took, because I had again passed out on the same spot of the sofa.

I spent most of the rest of the night without moving from that spot. She brought an alarm clock into the living room so that she could sleep on the other part of the sofa and still be able to give me the pain medicine at the proper times.

My memories for the rest of the night and most of Sunday are a bit hazy, but there are a few incidents that I can recall with extreme clarity. Unfortunately, some of these involve some basic bodily input/output functions, so if you don't like that sort of stuff you might want to skip over the next update when it gets posted.

The Operation

The gastric bypass operation took place on Friday, December 11, 2009.  Pre-op was pretty uneventful.  They put an IV in me, and I told the anaesthesiologist about problems I'd had before with nausea and with surpressed breathing response during recovery.  My wife came into the pre-op room and checked on me, then the nurses wheeled me away.

I don't remember anything about the operation, and I don't remember much of the recovery room.  I remember being groggy, and I remember having a urinary catheter and some other tubes sticking out of me.  Everything else is a blur, until some point later in the day when I found myself in my hospital room.

The uneventfulness continued through Saturday until a couple of hours before my discharge from the hospital.  I was still in pain, but I didn't feel like it was unusually bad pain.  I remember telling a nurse that I felt like I was about to have an anxiety attack.  They gave me something for it, and I calmed down shortly afterward.  No one thought that anything out of the ordinary was going on.

The problem is that something very bad was happening inside of me.  Things would get much, much worse within the next 24 hours.

Bad Omens

Okay, so the first doctor was a washout.  Fine, just find another doctor, right?  Sign up for his monthly pre-op orientation session, go, and get the ball rolling again.

It wasn't that easy.

I signed up for doctor #2's orientation session online.  The class was scheduled a couple of hours before I had to go to work (I've done a 9:00 p.m. to 5:00 a.m. airshift for years now).  I show up, and there's a note on the door - the meeting's been cancelled.  No warning, no phone call, no e-mail - just cancelled, no reason given.

The next day I called the doctor's office and rescheduled things.  Turns out I didn't need to go to his orientation session since I'd been to one when I was still considering doctor #1.  That'll teach me to deal with a doctor over the Internet - do it by voice, so you'll know who to yell at next time.

By the latter part of 2009 I was finally getting things squared away for my bypass.  I'd met the bypass doctor, got cardiac approval, had the psychiatric and other counseling done, got insurance approval, and was just waiting for a final appointment with the surgeon prior to the operation.  I was in a bit of a hurry at this point since the end of the year was fast approaching and my insurance deductible would soon re-set.  The Gods of Scheduling must have known this, because it seemed like there was a delay at every possible point.  Even that final pre-op session with the doctor was rescheduled to another day, just hours before the appointment time.

I'd considered myself lucky to have made it through the mindfields of dealing with doctors, hospitals, and insurance companies, but contrary to how I felt, my luck was running out.

Come the day of the pre-op doctor's appointment and my wife and I were sitting in the exam room, talking with the surgeon.  I was on an examination table that was rather high off the ground, and I had taken my glasses case out of my pocket and was holding them for some reason I can't recall.  Somehow I managed to drop them onto the floor on the right side of the table.  I bent over to retrieve them, and right as I got my arm to the floor I felt something go *POP* on the lower right-hand side of my rib cage.  This was followed by a pretty good dose of pain.  I had either pulled a rib cage muscle or done some damage to the cartilage between the ribs, but for some reason the surgeon didn't seem too concerned.  The pain would stay with me for the next four weeks and would impede my recovery, but I didn't know that at the time.

I should have recognized right there that I'd been getting bad omens for weeks.  I didn't even want to consider it, though - I was determined to get the gastric bypass, and I wasn't about to get superstitious before the operation.

Shows you what I know about superstitions, I guess.

(To be continued...)

What Came Before

Allow me to present a brief bit of backstory before I get into the tale of said disasters.  I first broached the subject of a gastric bypass to my wife in the spring of 2009.  She had just recovered from major surgery that had put us near our health insurance policy's catastrophic limit for the year, meaning I could get the operation and have it covered at close to 100%.  She thought this was a good idea, so I began looking into the matter.

The research and scheduling process took quite a while, partly due to work schedule issues, partly due to my own procrastination, but mostly due to red tape.  I had to start over at one point since the doctor I initially chose was a "participating provider" (i.e., one the insurance company would cover in full), but the hospital he worked out of was not.  I finally found what I thought was the right combination of doctor and hospital, but it took most of the rest of the year to do so.  The surgery was set, with only a couple of weeks to spare before a new insurance year began.

BE WARNED:  If you plan on getting a bypass or any other gastric surgery, allow yourself plenty of time.  You'll have to go through more screening processes than you ever thought possible, fill out enough paperwork to sink a ship, and deal with so many nurses, office assistants, and other administrative personnel you'd think you were being audited.  Do yourself a favor and type out as much of your medical information as you can in advance.  That way, you can just put "see attached" on the forms you'll receive.

(To be continued...)

Introductions Are In Order

Hello - my name is Lee Jackson, and I have a bit of a story to share.  It involves a bit of drama, a bit of comedy, a touch of cruel irony, and a huge chunk of physical pain.  It's complicated, to the point where it could be considered by some to be embellished or even made up.  Nevertheless, I swear it is true, from the start to wherever the finish may happen.

I will be changing names here and there to protect the innocent (especially myself and my family, mainly from lawsuits), but I will not be changing any of the facts to the best of my knowledge.  Granted, I may be a bit hazy on some of the facts, but on those points I will bring in my wife to confirm what actually happened.

The story begins on December 11th, 2009 at a certain hospital in the city of Dallas, Texas, where I had what was supposed to be a routine gastric bypass operation to help me lose weight.  What followed was anything but routine.

(To be continued...)