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Author: xraymd Big gold star, 5000 posts Feste Award Nominee! Old School Fool Add to my Favorite Fools Ignore this person (you won't see their posts anymore) Number: of 37076  
Subject: Home, sweet home Date: 8/16/2008 10:07 AM
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GREETINGS, EVERYBODY! I am finally back on line for myself and am glad that my beloved SolarCat did some pinch-hitting while I was indisposed.

You guys are awesome - in many ways as awesome as my surgeon himself, for the surgery was a procedure. YOU have helped provide the HEALING.

I am beyond grateful that the simple, innocent little word “indisposed” really CAN describe my operative and post-operative experience. There is nothing like resting on the softest cushion in the world of such a weave of true support and good wishes. Let me tell you, I felt it every moment and know with 100% certainty that the lift it gave me was really the largest part of the reason I was able to go home from the hospital as early as I did (I was discharged Thursday but my surgeon actually said to me at 7:30pm on Wednesday that I could even have gone home that night(!), only 2 days post-op after a major neurosurgical procedure. I knew very well enough that deciding to be discharged would have created a strain on all systems not yet prepared to have me so suddenly home, so wisely chose to remain until the morning, but it is a testament to how well I was already doing). Every moment at the hospital I felt like I had 100 of you at my back – kind of like that Verizon Network commercial – in a way that literally lent me strength. It was an unprecedented experience and my spirits remained high and I have never in my wildest dreams could have divined how fortunate we all are, for the community we have forged. It is at once the highest height and the deepest depth and we all have a reason to be collectively proud of the wellspring of goodwill and truly healing energy that we have amassed together. I will be 52 this month and can safely say that no matter how tight-knit my family and offline friends may be, there is nothing so unprecedented as having evolved us together as online friends who have bonded out of sheer goodwill and willingness to be of help and support. I’ve said it before: to me that is the most astounding technological marvel of our age (in many ways far eclipsing the airplane or the TV or the iPod) in that we have harnessed the personal computer and the Internet to create a spontaneous force for good. Good for us! And clearly good for me, for HERE I AM. :-)

Let me share some highlights and shout-outs because my hospital experience was also awesome. In the best tradition of Kasuma724, I will treat it as a tale as well as a kind of an interspersed packing list for anyone who will themselves or whose loved ones could be admitted to the hospital. *I* sure as heck could not have anticipated this so now I am keenly aware that life is what happens when you are making other plans. I am certain that my hospital stay is going to make me a better doctor and that is yet more of the good karma you guys made this experience into.

The tale:

From the get-go, I discovered that the hospital I round at is staffed by some of the most attentive and patient-oriented care deliverers (nurses, patient care techs, case managers) I could ever have hoped to have. Yes, since I work there, these are my colleagues, but having been the one in that bed, I can say with confidence that I saw nothing “VIP-ish” about my care and that the neighbor in the room next door to me was also receiving the same thoughtful care that I was. I had chosen from the outset to avoid being admitted anonymously (known around our hospital parts as NPNS – “no publish no show”) because I WANTED people to feel welcome to pop in. I trusted that if I were barfing or pooping or otherwise really out of it that the nursing staff would use their discretion to suggest a delay in entry and since I never had a lick of difficulty, there was every reason to be inviting. My nurses told me that I was the BEST patient because I gave forethought to what I needed and asked for things in bunches so I was able to spare their time and I know they were busy. But I was totally amazed that the few times I pushed the call button, the response was essentially instant (either the nurse or a patient care tech came in response) and my gentle inquiries of other patients on the floor told me they were having the same rapid response time. So I had NO ANXIETY when I was at my highest level of need.

The highlights began at once. I was taken to the pre-op holding area to get me appropriately gowned up for the procedure and met with the anesthesiologist. I shared my fret with him about worrying I could wake up in the middle of the procedure and that I might not be able to signal that I was not sufficiently under. He explained to me in clear terms that a layperson like my fiancé could understand why that was not likely in my case but that there were cases in which it could have been more likely (though exceedingly rare) – typically if it happens at all it would be during heart-lung bypass surgeries and that he and his fellow anesthesiologists had long since worked out a system to pre-determine whether an anesthetized patient was undergoing a “wake-up” and what to do to deepen the anesthesia. Hearing that this was something he’d so carefully considered simply erased any fret I had RIGHT THERE and that was just the beginning of the stage-setting for an increase in my comfort and confidence. The anesthesiologist took time to discuss the surgical positioning (I would be face down with my face in a cradle – the access to my back had to be unfettered) and whether I would have any significant facial swelling afterwards (I had NONE) and what he planned to do to alleviate any potential for post-anesthesia nausea. This was my first-ever general anesthesia and every bit of the magic he worked really DID work. I had ZERO nausea, not even queasiness, throughout my hospital stay or since. He just knew my weight and his meds so well, he got the doses orchestrated ideally. He did warn me about the post-extubation sore throat and I did have that but it was brief and did not interfere with my recovery.

I had arrived at the hospital at 5:30am. Surgery was planned for 7:30am and got started on time. I remember being taken into the OR and being told that I would be made very sleepy (I am sure they gave me Versed in my IV) and that they would work on placing a Foley catheter in my bladder and then intubating me and positioning me once I was out. And that’s ALL I remember of the surgery. What a blessing! I was grateful that I actually had a poop before leaving home that morning because that was one of my other concerns (what if I pooped during surgery?) but they were already well-prepared to deal with it. And as it happens (and as I KNEW would happen), I was on day 2 of my cycle – the heaviest day – and they were also completely prepared to deal with that, too. The surgical team were consummate professionals. I too am unfazed by my own patients’ body eliminations and of course I knew that my team would be unfazed by mine but since the patient was ME, it felt a bit different. I am not embarrassed nor shy but definitely am aware when there is any kind of an elimination issue and was glad I got it mentioned so I could then relax and forget about it, which I did.

I woke up in the Recovery area already extubated (YAY!) at only 11:30am – 4 hours later! Surgery was supposed to take 6 hours. But some absolutely excellent and beneficial decisions were made during the procedure that allowed for the chance at the best, least invasive outcome. Principal among the decisions is that my surgeon had to decide between a smaller exposure which could have shortened the incision or a wider exposure which gave him the best chance of excising the tumor without having to do it in a piecemeal fashion (meaning a lengthened surgical procedure due to the possible incision parsimony). He thought it through and went for the tri-level incision (the wider one). I could not be happier that he used his sound judgment as he did because of the gigantic benefits accrued. The tumor was in my thoracic spine at T8-T9, in front of the spinal cord, so harder to reach than if had been at the back of the cord. He had reserved the right to do a quad-level incision from T7-T10 if he’d needed to, but because of the way the tumor was aligned eccentrically leftward in the canal, it was sufficient to remove the lamina (the bony ledge off the vertebral bodies) on the left (the right side was kept completely intact) from T7-T9. This permitted him from having to extend the incision to something far more invasive called a costotransversectomy, which would have meant having to disarticulate the ribs in the target vertebrae’s pathway and would have been a far more major undertaking – that would have been the 6 hour surgery. But hey, he took ENOUGH bone as it was. The other huge advantage of opening up the left side of T7-T9 beside just being able to leave my ribs alone (yay!) was that the exposure of the tumor was so excellent that he did not have to have any instruments anywhere near my spinal cord and that he was able to get the tumor out en bloc (in one piece), making its excision decisive and leaving a very low risk of recurrence. He told me later that it had arisen not from a full intercostal nerve root, but from a rootlet and that my degree of post-op numbness in my left front lower thorax (kind of in my stomach area) was likely to be minimal and may even recede with time. I will TAKE that numbness in exchange for the spinal cord decompression the tumor removal conferred. Indeed, the nocturnal pain on lying flat is GONE and was gone the first night after the surgery. In his opinion (the pathology will take another week), he feels this is most likely a benign schwannoma (nerve sheath tumor). No question HIGHLY unusual and no genetics nor family history to point to why it occurred. But I am apparently in the age range of who happens to get these (3-4 per MILLION per year and guess I won the schwannoma lottery and I didn’t even know I was in the running) so even though we don’t know why, I decline to ask “why me” for the answer is “why not you.” So the surgery went FAR better than dreamed of before we began. The neurosurgeon had a device hooked up to me to measure my somatosensory neurologic action potentials during the surgery to attempt to detect any early dips in the signal from my spinal cord and the potentials before we began were stone cold normal and STAYED THAT WAY so despite the impressive degree of pre-op cord compression (my poor little spinal cord was being squashed flat by the big tumor), the cord really was working and did not diminish at all from the surgery. Post-tumor excision I was already out of the woods according to the neurosurgeon because the decompressive effect of lifting the tumor out of the way was really what my poor spinal cord needed for relief. The other major plus is that the neurosurgeon was concerned that I would lose a lot of CSF (cerebrospinal fluid) from if he’d had to take the tumor out in pieces, which he did not need to do that way, and I was therefore spared a horrible spinal headache that could have in and of itself derailed me for a day or two. No headache AT ALL! Since I was doing so well on post-op day #1, the neurosurgeon decided that I really did not even need a repeat MRI at that time – he felt that getting one in 3 months would be sufficient. I will probably always have a kink in the cord at T8-T9 (though it will start to expand) but the cord itself is expected to WORK and I should not be expecting to be at any specific neurologic risk. I had no plans to become a mountain climber (despite innocently hiking 1200 feet to the top of Masada in Israel at the end of June) but don’t see why I cannot ultimately become as active again as I may choose once he tells me I am cleared.

Anyway, the neurosurgeon (who is a bit of a wit) told me he used his pain-free scalpel and I believe him because one of the most startling and relieving things is how remarkably pain-free this has been. From the outset, he wanted to be sure that my pain would stay under good control and fitted me with a PCA (patient-controlled anesthesia) device which was set to have a continuous basal rate of morphine delivery plus deliver an extra dose at the push of a button controlled by me (with a 10-minute lockout between discrete dose deliveries and a 4 hour dose maximum). My angel of a nurse told me before hooking up the PCA what doses were initially chosen and I asked her right away to cut the basal rate in half (so I would only be getting half the dose in a 24 hour period than was originally planned for me) and she called the neurosurgeon who immediately okayed the reduction Among the risks of narcotic overload is of respiratory depression and I could already tell that after only 4 hours even at half dose, I was woozier than necessary so I asked the nurse to call the neurosurgeon again to see if the continuous delivery could be discontinued and to keep me only on the discrete button pushing system in which I had control over when to give myself a dose. He agreed at once because he trusted that I could tell when I was getting potentially overmedicated (I was on no meds at all prior to this surgical interval and am naïve to narcotics). But pain-free scalpel for sure because it is rather unusual for a patient to ask for and to truly need LESS pain medication following a major surgery than was planned. By the next morning he was able to eliminate the PCA entirely in favor of oral Percocet and even then I was using a total of 1.5 tabs over a 24-hour interval. I am astounded that I did not have more pain. But boy am I grateful, too. Evidently, even extensive bony dissection does not hurt nearly as much as an incision in a moving part of the body like the abdomen, and I have heard from my own patients that they have far more difficulty with pain control for anterior procedures than posterior procedures like the back. I am glad to find that this could be true of me, as well, for I have not needed any more degree of pain meds since arriving home on Thursday, either. I know when I am starting to hurt (the hospital thoughtfully gave out a pamphlet on post-op pain and described it as a pulling sensation at the incision, which is to me a completely accurate description) and half a Percocet solves it quickly, along with a brief interval of lying down. If this were a belly incision or an incision of another moving part, I am certain that half a Percocet would only confer half the needed relief or less, but I am truly managing with this lowest dose alone and I am NOT undertreating, for I know full well that way lies unnecessary discomfort. The rule of thumb is to treat early for it may result in a lowered need for narcotic at all. I thought the pulling sensation might have been muscle spasm so I did try a dose of Flexeril (a muscle relaxant) but that did nothing and so I skipped it thenceforth. I HAVE been diligent in taking stool softeners and laxatives because the urge to poop is not asserting itself and I do not want to add severe constipation to issues of healing. I am fully aware that the narcotics are doing this, minimal though they may be, and I am planning to be sure that I do SOMETHING to get those bowels moving at least every 48 hours.

Well, I now know the something that really works, for it worked in the hospital, and that is a Dulcolax suppository. Within 15 minutes of receiving one on Thursday morning, I had the first poop since surgery (yay!) so I know I have an exit strategy (no pun intended). That was really funny – my nurse that day who gave me the suppository said to me that she promised to forget what my butt looked like (since I am one of the physicians whose patients she takes care of) and I totally cracked up and said “You don’t have to forget! It will be a special bond between us that you got to put a suppository up my butt.” She and I always had a harmonious working relationship and now there will be humor on top of it, too. She gave me a big hug when she wheeled me out the car at discharge and wished me well for the next 8 weeks which is at least how long till I am back at work again. She also told me that all of the nurses and patient care techs really loved being able to take care of me because they all felt rewarded by how pleasant I was to them. It sure is easy to be pleasant when I am feeling well, free of pain and feel like any need I could have had was already anticipated. Early on in the hospital stay, I became a little hypotensive due to the anesthesia, the immobility, the reduced desire to drink and I needed a couple of fluid boluses which worked. Windowseat had advised me to have water on hand at the bedside. Even though the nurses were great about keeping a hospital-provided water pitcher filled up and poured for me into a cup because I did not have the initial steadiness to do the pouring without spilling, that’s exactly why the suggestion of a private water bottle with a straw came in extra-handy. I could keep my mouth moistened and myself hydrated without having to rely on anyone to help, despite how totally reliable the staff had proven to be at thinking ahead to what I might need.

My case manager got me a walker on post-op day 1 and the physical and occupational therapy teams were able to get me out of bed early. They gave me good handouts on spinal precautions and taught me techniques for dressing and transferring from lying to sitting to standing that utilized sound body mechanics and put the least strain possible on my spine and on my incision.

One of the speech therapists dropped me off a junky frothy novel unbidden saying that she’d heard a lot of patients liking it for being totally easy to consume. I thanked her but REALLY thanked her again later when in the middle of the night I was awake and not about to fall back asleep right away and my mind was roaming and hello, there is a junky frothy book I can read without any effort or concentration at all. It filled the bill perfectly and was exactly what I needed at the hospital. Now that I am convalescing so well at home, my attention span is deepening again and I am raring to go on more substantive reading that I want to concentrate on. Windowseat, the book you recommended is ready for pickup today at our library and I am ready for it! What I learned is that it was smart to take very lightweight reading material to the hospital, like photocopied short stories or articles, because there is a surprisingly low weight limit on lifting.

The neurosurgeon encouraged me to walk as much as I wished and I took him at his word. From post-op day 1 onward, I probably walked the length of the hospital at least 4 times a day – slowly of course at first, aided by the walker, but more and more steadily every day. The walker was highly useful inside the broad halls of the hospital but has been less useful or necessary at home in our human-sized abode. And I really am getting steadier and sturdier, and significantly able to manage shifts in position independently while protecting my spinal alignment. SolarCat wrote about how he felt I might be overdoing it but even he has relaxed since because he has seen that I am actually getting reams of rest and that I am actually not so stubborn. He has made suggestions that I have gladly followed and he feels like he is having a beneficial impact on this process. Boy is he ever! I may have set the walker aside but I have NOT set the toilet seat extender nor the shower chair aside. Those devices are godsends, as is the full body pillow my parents bought me, along with a Tempurpedic cervical neck pillow. Such comfort as I have never known! Also conferring tremendous comfort were a pair of knit socks from DrBooa which kept my feet cozy during the first post-surgical night when I had to wear SCD’s (sequential compression devices) on my legs to prevent blood clots. The socks fit perfectly and created a little pool of love and repose.

I received numerous flowers and cards from colleagues and loved ones. SolarCat actually had to borrow a Phillips head screwdriver to move the height of the brackets on some of the shelving inside the hospital room to accommodate some of the bouquets. He did a stellar job. What we did before leaving for home is to consolidate some of the bouquets into one vase to be able to leave the nursing staff a representative bouquet while still fresh for their enjoyment. We meant to bring in candy but forgot in the rush so we are planning to do so on Monday – the staff of the ward I was on are all to be commended and I made sure to tell the ward manager in my own words what kind of excellent care I received and I plan to formalize it in writing to the hospital CEO to reinforce what they are clearly doing right.

On the evening before discharge, SolarCat had asked my witty neurosurgeon about incision care. He told him, “come over here and I will show you. Let me take down the dressing (which he did). See the incision?” SolarCat: “Yes.” Neurosurgeon: “That’s exactly how you take care of it. No dressings. All you need to do is look at it and call me if it looks puffy or red.” So SolarCat is now in charge of incision care – not too onerous! The incision is midline on my back, running from about the top of my shoulder blade height to a few inches above my waist. The good news is I can wear waistbands or belts. The bad news is that it will not be a good idea to cover it with a bra strap for awhile, so I am wearing camisoles and loose tops, easy to get on and off. It’s lucky that I am small-breasted (B-cup) for I can forego the support without undue discomfort because I can tell that lying down on the incision, or sitting against a chair back, is about all the contact it wants right now. The neurosurgeon has cautioned me about adducting my arms (like in a self-hug fashion) for that would induce a stretch on it which would unnecessarily widen it. That incision is actually precious to me however it heals because it represents a new lease on life. I had been bedeviled since 2004 with an imperfectly-healed skin graft at the infra-tip of my nose (a little harder to handle because it is visible) but one of the true side-benefits of this sudden need for surgery is that I am finally once again coming to love the skin I am in and am now prepared to accept my former facial flaw as a current style alternative (“it’s not a bug, it’s a feature!) because it seems so honestly insignificant in the face of what else has transpired and thankfully the self-esteem sands have shifted the right way again so that old whine is now history and I will sport my nasal “elbow patch” proudly even as the back incision is healing. The neurosurgeon did give me a good guideline for keeping track of a good series of stages to anticipate the incision to go through on its way and when he next sees me in 3 weeks, we will know whether it is on pace.

So thanks for listening to my story. It feels good to tell it. SolarCat and I are eagerly awaiting a return visit from Cassandra, Gordon and Nate, whose happy juju magic is like the stars in the sky and is ineffable in impact. But so is the magic we’ve created together on GO! Malaoshi, I am so relieved that DD is back home with her newborn son. Today is newborn, too, and I plan to usher it in in tranquility.

Love,
xraymd
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