Sunday, February 15, 2015

PART IV: Recovery and Hurdles Along the Way

This section will be in "diary" form and I've included this entry largely for my own perspective, though I hope it will be of interest to others who have had quadriceps tendon repair. It's just my own experience -- if there's anything I've learned it's that each individual progresses at his own pace.

January 16, 2015 "Operation Day"

Early day -- 6:00am at the venue where my surgery would be performed: Texas Orthopedics in northwest Austin. I don't really remember much about this day other than they knocked me out and when I came to, I had a big bandage on my right leg. I had opted for a "nerve block", so I could feel absolutely no pain at the incision. Somehow, Dana managed to get me piled back in the car, and we picked up the prescribed pain meds on the way home -- Hydrocodone for pain, and Diazepam for potential muscle spasms. I was pretty much out for the day.

January 17, 2015 "The Day After"

I slept... the nerve block was still in effect so I didn't really need pain meds. However, I couldn't get up easily, though this is just something you learn as you go along. I actually had to have a PT person come out to show me such tricks as getting up out of a chair, going down and up a single stair (our house has TWO of these small steps.)

January 18, 2015 "Fun (or NOT) with Diazepam"

The nerve block began expiring. Post op instructions said to try to stay "ahead of the pain". So... I tried. However, I soon learned that Hydrocodone and I do NOT agree on many things. I don't have the nausea that many people complain of, but did have the following: rash, itching, drowsiness, depression, and BIG time issues with NUMBER 2. Ouch...

When my leg began twitching, I added the diazepam to the mix. Turns out, I also experience many of the side effects of this drug, too -- particularly "impaired motor functions", "impaired coordination", "impaired balance", and, apparently a touch of the "anterograde amnesia", since I really can't remember much from the days I took diazepam.

Unfortunately, this kept me off my feet (on the walker) for a couple of days... who needs a setback at this point in recovery.

January 26, 2015 "Learning to Scoot"

I had my first follow-up appointment with the Orthopedic Surgeon. They removed the staples and said the incision was healing well. My mobility at this point is still "light toe touch" on the walker.

Let me tell you... getting 20 feet on a walker with "light toe touch" is an athletic feat. My triceps will be good and strong after this, even if everything else is completely gone to pot.

The plan was to begin early PT around February 9. I was eager to continue down the road to rehab.

February 2, 2015 "Pain in the Ankle"

I began having severe pain in my right calf. By Thursday, the pain was so intense that I had trouble making the 20 foot trip to the bathroom.

February 5 - Feb 10, 2015 "Six Days on the Road"

The calf pain was worse... I called Texas Orthopedics. My surgeon's physician's assistant told me to go to ARA (Austin Radiological Association) for a ultrasound on my leg... N O W. So... we piled into the car.

I figured that they'd do a test... tell me everything was fine... go home and bite my lip. But... this is NOT what happened!

Instead, they told me that I had developed major blood clots in my femoral vein and multiple pulmonary clots. Serious stuff. They told me to go immediately to ER. We did, and I went from ER to ICU where stayed for the next three days.

I was first told that the pulmonary clots were the most dangerous and that they were planning to do a "procedure" to stick some sort of tube down my neck into my lungs, then pump a drug (something like this link) to break up the blood clots.

However, after the radiologist reviewed the CT Scan, the physician in charge decided the pulmonary clots were too small to be dangerous and that they should perform the "tPA" procedure on my leg... let the body take care of the pulmonary clots.

They did something to desensitize my leg, and gave me some mild sedative. First in was a "portal" about the size of a coffee stirrer into a vein in the back of my leg. Through this, they threaded three IVs (or a XII -- ha ha) into the vein. One tube carried the tBA (the clot busting substance"; a second was an Ultra Sonic carrier -- high frequency vibrations; and, the third was a saline cooling solution to keep the Ultra Sonic motion from overheating my body. All this was guided in real time via an X-Ray display. When the tubes were all inserted, I could still see two of the captured images on the displays -- one of my hip joint, and the area in the femoral vein where the largest part of the clot resided. The other image was just below the knee, the portal insertion joint.

The attending physician, Dr. Poley, told Dana that I'd slept through the whole thing. I'm glad that I fooled them... I was awake for the whole thing!

From Radiology, I was moved back to ICU. Seton has some good staff... attending nurses (Travis, Josh), clinical assistants, and attending physicians (Dr. Kalyanaswamy... pronounced exactly as it's spelled) were really good, friendly, responsive to questions, and informative. This is good -- I was to keep my leg immobile for at least 24 hours.

Sometime during the night after this procedure, the insertion point began oozing blood -- not just a little bit. I mean it was pooling on the floor. The nurse on duty, Josh, was, I'm sure, alarmed. However, he immediately called the company that provides the equipment for this procedure, and managed to reach Dr. Poley. It turns out, although it's not what they intend, it's not unusual. Keep in mind, the insertion portal was like a coffee stirrer or small soda straw. So... .they just cleaned, changed pads under the leg, until morning when the redressed the leg.

Late in the morning or early afternoon, the opted to inspect the progress. I was taken back to the same (or similar) radiology lab, where they examined the blood clot. Once again, I was sedated, but awake, and I heard a round of "look at that!" from all the staff. Turns out, this was the GOOD response... the clot was largely dissolved and full circulation was restored to my leg. They pulled the entire apparatus out. Before closing the portal, the sent a "stint" up the vein (similar to how they do the heart thing), to help clean the vein. Back to ICU... until Sunday when they moved me up to the orthopedics wing for recovery. Much better... much MUCH better.

I still had a couple of days to spend in IMC (intermediate care) while they fed me Heparin, a powerful anti-coagulant, and monitored my blood by withdrawing copious quantities from a dozen or so pin pricks in my left arm.

I'm glad they were doing all this, but what I can tolerate five, six, seven... maybe even eight times... becomes REALLY irritating the fifteenth or twentieth times! Yikes... what do they do with all that blood?

Finally, on Tuesday morning, Dr. K (what they call Dr. Kalyanaswamy) came by... I asked when I might be released. She said, "This morning... in about an hour." I have to admit, it brought tears of joy to my eyes... I immediately called Dana. She was caught off-guard, but was equally as happy as I.

My advice... Seton is a really good hospital, and the people are very nice and seemingly quite competent. However -- DON'T GET STUFF THAT MAKES YOU WIND UP IN THE HOSPITAL. "Out of the" is a much better relationship to the hospital than "in the".

I'll be taking a blood thinner for probably 3 to 6 months, and this is not without issues. But this is a relatively new drug call Xarelto and doesn't involve dietary restrictions or constant dose monitoring and dose alteration like the alternative, Coumadin. Unfortunately, being new to the market and sold only under the brand name, Xarelto is also expensive.

A really proactive and energetic social services person at Seton, Emily, found me a card that would cover the first 15 days of Xarelto, for which Walgreens was asking $565. THANK YOU EMILY!!!

Walgreens, by the way, was less than helpful about anything. As a result, we had the prescription transferred to Costco where, as in every other aspect of Costco's operation, the pharmacy staff was very helpful. Also, for the same prescription that Walgreens would charge me $565, Costco would have charged about $300. So... next time you start to go to Walgreens, think twice. Go to Costco -- if you don't have a membership, GET ONE!

So... out of the hospital... .home... back to learning to walk again!

February 12 "Checkup"

I had my first post-hospital appointment with my primary care physician. I had written down all my questions -- the most important of which was, "Can I re-start rehab on my leg?" The answer was affirmative... if I could have jumped up and click my heels, I would have. Oh happy day.

Possibly the most interesting aspect of my trip to Austin Diagnostic Clinic was getting from the car (Dana let me off at the circle drive entrance while she parked) to the doctor's office on the 2nd floor.

I told Dana that I'd meet her inside. My means of locomotion is a walker, an alternative to crutches which I just don't trust -- I mean, why not a pogo stick?

However, moving with a walker when you're restricted to "light toe touch" on one leg is physically demanding. You take a step on the good leg, then lift yourself fully off the ground with your triceps, lightly touch the toe, and quickly again support yourself on the good foot. Although I know much of my body has suffered from this whole event -- obviously, I have not been able to play racquetball -- my triceps will be powerful. Going the 200 or so feet from the entrance to the office was exhausting. Thankfully, Dana found a wheel chair and I got a free ride for about half the distance. There's got to be a better way, you would think.

February 16 "Learning to Bend"

For my visit to my orthopedic surgeon, I was rewarded by the loosening of my leg brace to 30 degrees flexation, and no lock on extension. And, the big thing... I can place full weight on the "bad" leg. Instead of hitching along on the walker, I can move normally -- the walker just serves as protection. I've been running laps inside the house -- currently trying to get 200 - 250 steps a day.

Also, I began Physical Therapy (PT) on February 20. I selected Austin Physical Therapy Specialists... I read good Yelp reviews, and the office is very close to my house -- within walking distance... er, if I could actually walk.

March 1 and March 2 "Return to the Stage"

I played my gigs on March 1 (Jim's Country Jam) and March 2 (The White Horse). I refuse to use a walker to get into a gig. I had human crutches. Since I can walk reasonably well, albeit slowly, I just needed reliable support, similar to what's provided by the walker. My wife and I practiced at home for several days before the gigs.

Of course, the tricky part is stairs. At the March 1 gig, there is a flat path into the venue, but three relatively steep steps onto the stage. Going UP is easy -- good leg on the step, raise and plant the bad leg. Going DOWN is harder... bad leg leads and there's a tendency to flex and support with the weak quadriceps. This was a preview a feeling I'll probably fight for months, if not years, to come -- this is how my leg was injured in the first place... going down stairs.

The other challenge to playing gigs is that I have very little stamina. Even sitting on a chair, playing and singing uses considerable energy. As of March 3, after these two gigs, short as they were, I'm pretty exhausted. I'm playing only 9 shows in March 2015 as compared to 29 shows in March 2014. I'm not sure when I might feel like working more.... I'll just take it day by day.

March 3 "Walk In PT"

Today was my fifth PT session. A session consists of:

1. Electro-stimulus. They attach four electrodes to above and below, on each side of my knee. A current passes between the electrodes that automatically contracts the muscles surrounding the knee. It feels much like allowing a pack of crazed, microscopic gerbils to run wild under your skin. It doesn't really hurt -- but it's a little disquieting. And it really does feel good when it stops.

2. Deep message of the quadriceps. Since the muscle is partially atrophied, this can be painful -- but I'm sure this is vitally essential at this point to prevent adhesion and to promote circulation.

3. Ankle Pumps. This is a seemingly trivial, but very important exercise. You just elevate your feet, dangle your heels over the edge of the support, and wiggle your foot. It helps to reduce swelling and to prevent blod clots -- I sure don't need any more of those! I'm doing a set of 30 at least twice a day.

4. Quad Sets. This exercise consist of flexing the quadriceps muscle, just short of the pain threshold. Again, I'm doing these daily, twice daily, 30 reps holding for 5 seconds each.

5. Squeezing ball between my knees. I don't know the name of this exercise, however, it's the one exercise that makes me feel a little lactic acid buildup -- a good burn.

6. Heel raise. Lay back, knee on the riser, high side at the knee -- lift my heel as high as possible, short of pain. It's pretty obvious what this is intended to accomplish, given that this is the primary function of the quadriceps muscles -- extension of the leg.

7. Laser treatment. This helps with the scarring from the incision. It gets a little warm, but it doesn't hurt and it seems to work. The incision is now completely healed. The scar will be there for life -- but it's just another of life's tattoos.


Sunday, February 1, 2015

Up to my Knees, Head First

I've written a series of posts related to my recent knee injury. I wrote that for several reasons:

1. They'll explain what happened and why I'm absent from my gigs;
2. They'll be a helpful resource to others with similar injuries;
3. They'll be characteristically witty and entertaining to read, and not become known as "Stringer's Pity Papers";
4. I don't really have much else to do while I've been lying around waiting for this knee to heal;
5. And last, a chronicle for myself and family... the first three won't change much... the last two, I'll try to keep up to date.

PART I - What Happened

PART II - What is a Disrupted Quadriceps Tendon

PART III - Getting Treatment

PART IV - Recovery and Hurdles Along the Way

PART V - Some Life Lessons

I would appreciate comments and reposts.



PART III: Getting Treatment

How I Did It vs. How it Should Be Done

I injured my knee on the evening of December 26, 2014. I had surgery to repair the injury on January 16, 2015... exactly 3 weeks.

All the authoritative sources say you should 1) be taken to the emergency room; and 2) surgery should be performed as soon as is possible. The tendons and muscles begin atrophy almost immediately and the repair becomes more and more difficult, and less and less effective!

So... what happened?

First... I'm an idiot musician -- the show must go on. I felt that I need to play the show at Belly Up, regardless of the fact that my role was a bit part. In my nearly 55 years of playing gigs, I can count on one hand that shows that I've cancelled because of health issues. I played my Hall of Fame show in 2007 with a 104 degree fever and walking pneumonia!!! In a snow storm!!! In sub zero weather!!! Geez... you get the picture?

Second... as I mentioned, I have a history of pulled muscles. I sort of figured that's what it was... I'd do the RICE treatment, limp around for a couple of weeks, and that would be that.

Third... we were 1800 miles from home looking at a 3 hour plane trip. We delayed our trip for a day (which cost nearly $600 for ticket alteration, extra car rental, extra hotel, etc.) to allow a trip to the Urgent Care Center... by that time, because of the excruciating pain and my inability to extend my foot, I knew this was not a pulled muscle. So... we went to a recommended Urgent Care Clinic in Mission Viejo... more about this a bit later.

Fourth... it was Christmas holiday and orthopedic surgeons apparently are orthodox observers of this holiday. Though I tried to get an appointment with my primary care physician (PCP), as of Dec. 28, the first appointment available was not until January 2 -- that doctor was on holiday. My PCP referred me to an Orthopedic Surgeon... the first appointment I could get was January 6. At that appointment, they set me up for an MRI on January 8... and I could not get the results until January 12. At that time they said I needed surgery ASAP... well DUH!!! 

Ok... as many of you know, I quickly called about 100 people to find replacement geetar players, get the OK from bookers, etc. Everyone was, of course, very nice and I'm eternally grateful to my friends and colleagues who accommodated my sudden schedule change.

But... surgery finally occurred three weeks from the accident.

How it should be done -- GO TO THE EMERGENCY ROOM! This is a serious leg injury, one that if left untreated, can leave you permanently hobbled. I may not be young, but I tell you what -- I''m not ready for the now or EVER!!!

Now... I have to comment on the Oso Urgent Care Clinic, and in particular, Dr. Joy who examined my leg. I described my problem thus (reiterating much of what I've written on other pages.)
  1. I injured my knee when I missed a step;
  2. I heard a loud "pop" when my leg buckled;
  3. The incident was accompanied by intense pain in the patella;
  4. My knee was extremely swollen and discolored;
  5. I could not extend my foot.
If you do a search on Google for "Quadriceps Tendon Rupture", you'll get millions of hits. Each one with list, almost literally, the symptoms I've described. However, here's what Dr. Joy, in his medical wisdom, told me: "It's bursitis."

Once my head stopped spinning around on my neck, I inquired, incredulously, "Correct me if I'm wrong, Doctor... bursitis is a chronic inflammation of the bursa in the knee.. it would not suddenly be brought on by a slip on some stairs, would it? I was FINE before this incident... these symptoms began simultaneously with my slip on the stairs."

Dr. Joy was unshaken in his medical wisdom, even though his "diagnosis" was the equivalent of suggesting to a patient who had come in with a knife protruding from his chest, that he had acne. A little tetracycline would clear it right up.

As treatment, Dr. Joy wanted me to take a powerful steroid (methinks someone close to this situation might be taking a few too many of these, himself), and, thankfully, some Vicodin, to at least allow me to make the trip back to Austin.

Of course, what Dr. Joy SHOULD have said is, "Oh geez... you've ruptured your quadriceps tendon.... we need to get you to an emergency room, quick", or at least, "Oh geez... this looks serious and I don't really know what it is... let's get you to an emergency room."

Now... I realize I've named names, and left myself somewhat at risk. However, I have his written diagnosis and I have my wife as a witness. This is possibly the most irresponsible medical behavior I've ever personally experienced. Gawd forbid, my issue was not a stroke, or a heart attack... he might have diagnosed it as fatigue, or indigestion, depression, or who knows what. I have NEVER in my life levied blame against a doctor... what they do is difficult, and involves a certain amount of guess work. However, in this case, we have filed a formal complaint to the California Board of Medicine. Someone could die, next time -- my hope is taking the time to file the complaint my help prevent a needless death. No lawsuit, no damages... I just don't want this clearly incompetent "doctor" ruining someones life.

THERE... done with the vitriol. If you have a medical issue which requires "urgent care", I'm sure there are alternatives to the Oso Urgent Care Clinic.

One again, how it SHOULD be done -- GO TO THE EMERGENCY ROOM.

Next up... PART IV: Recovery