Left Hip PAO -- The Surgery Itself

For the most part, today* was much like Surgery Day for my right hip PAO. Same fitful night of sleep, same chilly walk to the hospital, same admitting and pre-surgery procedures.

This time, however, I had a cold. It seems like I never really got back to 100% healthy after that cold I had in late September after my first autologous donation. As you'll recall, I had a mild cold during/after the first autodonation, and an oncoming sinus infection during the second and third.

And then two days ago I began to have a sore throat. By last night I could tell that I definitely had a cold (or maybe even a continuation of that same unconquerable sinus infection? Please, don't let it be that!). I was very nervous that today's surgery would have to be postponed, which would have been a logistical nightmare.

Last night I tried to get a good long night's sleep (perchance to heal myself of the cold overnight?). Of course that was not to be, and I had a horrible, fitful night filled with nightmares about the surgery being cancelled, interrupted only by the frequent need to blow my nose.

This morning, the pre-surgery procedure was pretty much the same as it was with my right hip PAO in March. Mom and I walked over to the hospital. I had my vitals and other checks done at admitting. I mentioned there that I had a mild cold but the admitting staff didn't seem too concerned about it as long as it wasn't a cough/chest problem.

Because I had waited around at admitting for so long, by the time I got up to the surgical floor, my medical team was waiting around for me. I didn't even get a chance to change into my surgical pajamas before Dr. Millis signed my hips, his resident Dr. LaRue introduced himself and talked about the surgical strategy, the nurses came to check various things, and the anesthesiologist gave his explanation of the procedure. I did tell them that I had a mild cold but they, too, said they'd be more concerned if it were a chest/coughing cold with fever than the nasal congestion cold I had.

Then the anesthesiologist injectected me with the loopy-loo sedation medication and I was wheeled in to the OR at 7:50. I do remember joking around a lot in the OR as the team prepped me and placed my epidural. I remember there was music playing in the background and I asked what kind of music they were going to play while they operated on me. He asked what I wanted and I told him definitely no heavy metal, as that might make him go overboard with the saw. I think I eventually settled on Händel's Water Music.

While I was in surgery, my mother got regular updates on my progress. At 9:30 Dr. Millis had started in on the left hip, and by 11:00 he was cutting bone. By 12:30 he was putting the screws in on the left side. At 14:15 Dr. Millis was preparing to take the screws out of my right hip. Finally at 15:30 Drs. Millis and LaRue came out to tell my mother that I was all done and the surgery had gone well. He also gave my mother a baggie with the five screws that had come out of my left hip. Souvenir!

Dr. Millis did mention that my superhuman bone density had surprised him once again -- this time he was prepared for how difficult my bones were to saw through, but he was not prepared for how tightly my bones would adhere to the screws in my right hip during the past seven months of recovery. Apparently they had a heck of a time getting the screws out!

He also explained that this left hip surgery was somewhat less invasive than my right hip PAO had been, since my left hip was in better shape going into the surgery than my right hip had been. This time they did not have to open the joint capsule or detach the head of the quadriceps muscle. Also the femoral head did not need to be shaved and shaped for better alignment this time either. Thus the surgery itself was faster and my recovery will likely be quicker and less painful as well.

While Dr. Millis was giving this auspicious news to my mother, I was in the recovery area, awakening from anaesthesia in what felt like the throes of death. I felt like I had hypothermia, and I was shivering so violently that it would be more appropriately termed convulsing. I was also gasping for breath, literally gulping huge lungfuls of air but still feeling as if I could not breathe, as if I was drowning. I was given oxygen and was covered in hot blankets over every inch of my body like a heated white burqa. I remember pleading with them to stop the shaking; they ended up having to give me a horse's dose of Demerol to calm it.

By the time my mother came into the recovery room to see me, I was breathing normally and my convulsions had been reduced to chattering teeth and an occasional body shudder. I was still covered in blankets as they brought me up to my room. I was given some Nubain for the itching and promptly fell asleep.

*Obviously, I did not write this post on the day of my surgery. I wrote it a few days later, but post-dated it for chronological consistency.

LPAO Pre-Op Appointments

Today my mother and I were back in Boston for a combination post-op / pre-op visit. Seven months post-op for my right hip, two weeks pre-op for my left hip. Overall it was a long day with some confusion and scheduling mishaps, but everything got done and everything is great, at least with my hips.

I had my appointment with admitting, which was much quicker this second time around. I signed my various proxies and consents and I spoke to the anesthesiologist and the admitting nurse. My insurance pre-authorization is "in process," so hopefully I'll get the confirmation in the mail any day now.

I had my third and final blood draw at the hospital blood center, and then I went up to see Dr. Millis. The scheduling mishaps meant that Dr. Millis did not have my pre-op left hip MRI or my post-op right hip X-rays to view prior to me seeing him, but nevertheless he put me through my range of motion tests and discussed both hips with me. My range of motion was great; nothing hurt; my muscle tone and fitness were much improved since my last visit in July.

Finally, on our way back home, we stopped at Waltham so I could have my pre-op MRI and post-op X-rays. The nurses had a lot of trouble injecting the contrast for the MRI because my veins kept rolling away or blowing out, even when they used an infant needle. They had to stick me six times to get 30cc of contrast into me. Clearly it was a wretched experience, especially at the end of a long and draining day. Pun intended.

My biggest concern today was really my general health and the useability of both today's blood draw and my two prior blood draws. At the hospital blood center (unlike at the New York Blood Center), they told me to contact them if I got sick with a cold or flu-like symptoms within 48 hours of my blood draw. This was a concern because, as you may recall, I got sick after both my previous blood draws.

My first blood draw was September 25 and I believe I wrote that I'd woken up that morning with a raspy throat and immediately fell into a (relatively mild) cold after the blood draw. My second blood draw was October 5; I woke up that morning with pressure in my left sinus and was diagnosed the next day with a sinus infection. Obviously in both cases I was already sick when I gave the blood.

Today I asked the blood center nurse about both cases and she felt fine about the first draw but wanted to run the second draw scenario by my doctor. Dr. Millis was fine with it but said we'd use the October 5th pint last, if necessary.

The problem is that today was my third blood draw, and I am still not 100%. In fact, I finished a 10-day course of antibiotics for my sinus infection three days ago (on Saturday 17th), and unfortunately woke up yesterday with the realization that my sinus infection was back. It had not been vanquished by the 10 days of antibiotics. I have to admit I didn't take super-good care of myself during the course of the antibiotics; for example, my sleep schedule was messed up by a trip to Los Angeles.

So today I have a sinus infection and I had to give my third blood draw. This on-site (in Boston) pint gets separated out for its plasma so maybe that mitigates things? I don't know. It is worth noting that (without knowing about the sinus re-infection) the admitting nurse checked my general health, including lymph nodes, looking in my nose and throat, breath sounds, etc. and declared me healthy. If I was really really sick, she'd have been able to tell, right?

I told Dr. Millis about my sinus infection and asked him if I could get back on antibiotics and take them until just before my surgery and he said yes. So that is the plan. I am going to try my very hardest to take the best care of myself possible these next two weeks (which I already should have been doing, but anyway) and hope that this second course of antibiotics can kill this thing. Obviously if it doesn't, there goes my surgery date.

The Surgery Itself

My mother and I made the chilly, five minute, pre-dawn walk to the hospital. Right on time at 6:00am I made a point of bounding up the hospital stairs towards the Admitting department, ticking off my last "last" before surgery. In the Admitting area there were three other patients with their families checking in for surgery. All of them were kids, except for me, which I guess is to be expected at a children's hospital. They were, alternatively, sniffling and clutching a teddy bear, silent and affectless, and moderately cheerful. I was actually a bit jocular and excited, which seems an utterly inappropriate mood with which to approach major surgery.

By 7:00am we were all in the pre-op holding area, a room lined with curtained off alcoves, like stalls in a barn. In my "stall" I changed into my surgical "johnny" gown and met with the anaesthesia team. They reiterated everything that had been discussed about anaesthesia during the pre-op meeting in February.* In some PAO blogs I'd read that some patients had experienced problems with their epidurals where the wrong leg was numbed, or the epidural did not work at all. When I mentioned this to the anaesthesiologist, his answer seemed to be something like: "yes, that happens sometimes; it is tough to pinpoint the right spot; we are actually working blind in there because we are not going to bring in a fluoroscopy for a simple epidural, but we do these all the time so it should be fine." Oh, OK, now I feel better.

Dr. "Woody" Sankar came to sign my hip and Dr. Millis, sporting a green St. Patrick's Day bow tie, stopped by to answer last minute questions. He estimated he would be done with the surgery by 1:00pm. After the doctors left, the anaesthesiologist gave me "something to relax" through my IV -- I don't know what it was but it hit me almost instantaneously.

Quickly thereafter, at 7:45am, I was wheeled into the operating room and my mother was taken into the family waiting room. I didn't have my glasses on anymore, but through the fuzz I saw that the OR was full of a lot of people, a lot of tables and a lot of stuff on the tables, everything in the blue/steel/white color palette that looks so good with my complexion. I also remember thinking Dr. Millis' surgical cap was not at all like the caps the surgeons wear on Greys Anatomy.

My gurney was wheeled close to another bed, which had been piled with pillows or cushions of some kind, and I was told to swing my legs around so I was sitting on the side of my bed resting my shoulders, forearms and head on the cushions. "Try to make your back into a 'C' shape," the anaesthesiologist said.

Wait just a minute, I thought. This is the procedure for getting an epidural. I am not supposed to be conscious while getting an epidural. I am not supposed to remember this part. I am way too conscious for this. Meanwhile people behind me are telling me what a great spine I have and what a wonderful "C" shape I've made with it, and Dr. Millis and his strange surgical cap are right in front of my face talking about things completely unrelated to how overconscious I am during this epidural placement. Dr. Millis is holding my hand and the man behind me is saying "this is some local anaesthetic, just a small pinch," and I recoil from the not-small pinch and am told to hold still. At which point I think, oh God, this epidural thing really going to blow and I am far too conscious!!, but then it just a bit of pressure and it is done. The man behind me asks me if it tingles on the right side or the left side of my spine and I tell him it is the right side and I am conscious enough to know and be relieved that the right is the correct side for this epidural to work.

So then many hands help put me on my back on an operating table, and Dr. Millis puts this fleshy plastic face mask over my nose and mouth and I remember he was talking to me and holding my hand and I was frustrated because I wanted to answer but I couldn't because of the windy face mask. And then I was gone.

Since seeing me off by the operating room door, my mother had been waiting in the family area. At 9:30 she was told that all was going well and that my surgery had begun at 8:45. By 11:00am the doctor had begun making cuts into the bone but had not inserted any screws yet. By 12:30pm the doctor had discovered the superhuman bone density of my skeleton and was still cutting bone and was now estimating two more hours of surgery. By 3:20pm the doctor was almost finished and was closing the incision, but the nurse said he would not come out to talk to my mother until I was awake and moved into my bed in the Post-Anaesthetic Recovery Unit (PACU).

Meanwhile, I was coming to in the PACU in what should have been relatively pain-free awakening from general anaesthesia. Unfortunately, during the surgery my left arm had been placed in a position that normally would have been comfortable but in my case was not. The left arm had two IV lines, an arterial line and a blood pressure cuff on it, and was stretched out straight across a table, supported with pads and gel packs. Despite all those protections, my left elbow somehow hyperextended, causing straining or microtearing of the tendon attaching my biceps muscle to my radius.**

I can't even remember if I had any hip pain at all when I woke up because all I remember is excruciating pain in my left elbow. My cries utterly confounded the PACU staff who were (understandably) under the impression my hip was my most likely pain locus. All I recall from this period in the PACU is whimpering and moaning and leaking tears as people tried to figure out what was wrong with me. No conclusion was ever really reached, but I was given morphine anyway, which helped a little.

At 4:10pm Dr. Millis came out to the family waiting area to speak to my mother. He said the surgery had gone well, and that I was out and awake and feeling no pain in the hip, but that I was feeling pain in my elbow. He also mentioned that I had very strong bones, which was why the surgery took longer than expected. Dr. Millis showed my mother films taken during the surgery as the bone was cut, moved and after the five screws had been inserted. The doctor showed a comparison of my pre- and post-surgery hip socket angles -- my pre-surgery angle was 90 degrees and the goal for the surgery had been to increase the angle to at least 110 degrees. The post-surgery angle was actually 114 degrees, so Dr. Millis was obviously quite pleased with that outcome.

You can see the increased coverage of the femoral head ("ball" of the joint) in the image to the left. Compare my left and right hip socket coverage and it is obvious how much more of my right femoral head is in the socket compared to the left femoral head. Obviously all my new hardware is quite visible as well.

The doctor also mentioned that he had not used all of the pints I'd autologously donated prior to surgery, since most of my blood replenishment during surgery came from the cell saver system. But he would probably be using some of my donated pints to ease my recovery in the next few days.

At 5:30pm my mother came to see me in the PACU. I was already on morphine for the elbow pain, so my hysteria had lessened slightly at this point. She fed me ice chips while I kept trying to clear my throat of the breathing tube feeling. While she was there Dr. Millis and Dr. Sankar were adjusting my CPM machine, which I would use for the next few days.

At 7:00pm, twelve hours since I'd first hit a gurney, I was wheeled into my room on the 10th floor. Luckily, I had a private room with a lovely view. I didn't spend much time enjoying the view, though, as I was exhausted -- from the surgery, the sedation, the pain, the morphine, everything. I think I was asleep by 8:00pm.

* All quotes and dialogue attributed to medical staff at Childrens' Hospital are taken from the memories of my mother and my(drugged)self, and should not be considered direct quotations or perfectly correct paraphrasing.

**This is my diagnosis, not a doctor's. But I still think it is right.

Surgery Day - Morning

My surgery time is 7:30 this morning; I have to be at the hospital at 6:00am.

Yesterday my mother and I drove up to Boston; we stayed in a hotel last night. My mother will be staying there for the week. (For others having Boston surgeries, it is the Best Western Longwood, a block or two away from most of the Longwood Medical Area hospitals, including Childrens', Brigham & Women's, Beth Israel Deaconess, etc. There is a special rate for relatives of hospitalized patients.)

I did eat a smallish dinner last night. The pre-surgery eating guidelines allow you to eat up until midnight the night before the surgery, but they recommend having only a light meal. Post-midnight I can drink water until three hours before the surgery, i.e. until 4:30 this morning. Which is basically when I woke up from a night of pretty fitful sleep and could not fall back asleep. So I did get about a liter of water in me just under the wire.

I did not bring very much with me for this hospital stay -- I can't imagine I will need much that won't be provided by the hospital or available on site. (There is a CVS/pharmacy in the lobby of the hospital, and since Longwood is a neighborhood of hospitals and medical facilities, anything I could need is probably available within a 5-block radius.) My packing list included:

- glasses, contacts & solution
- my favorite sheepskin slippers
- cardigan sweater
- reading material
- laptop
- gym shorts
- pyjama pants
- bathrobe
- crutches (which I had leftover from a sports injury a couple of years ago)

Even that seems like a lot given that I'm not going to be able to get out of the bed for several days, much less change out of the hospital-issue gown I'll be in through and after surgery. The shorts/pants, bathrobe and slippers are really for later in the week when I'll be out of bed taking my first steps with the walker and then crutches.

This morning my first stop will be Pre-op Admitting to finalize my admission to the hospital (most of the admitting paperwork was done in February at my Pre-op visit). The nurse there will take my vitals, confirm that I have complied with all the appropriate medication/food/liquid restrictions required in the weeks and days before surgery, and get me changed into my surgery attire.

Next I will go up to the surgery floor, where I will meet with Dr. Millis and the anaesthesiologist. Dr. Millis will sign my hip to indicate which surgeon I belong to and which hip he is to operate on. (I suppose all patients look alike when supine with surgical bathing-caps, breathing tubes and billowing pastel gowns, so one must take more basic measures for identifying one's patients -- like writing on them with Magic Marker. You know there must be a lawsuit or two behind that rule.) Next the anaesthesiologist will start the IV, and hopefully that is the last thing I shall remember.

So now it is time to head over to the hospital. I feel tired and hungry and cold, and everything else you feel at 5:45am on a March morning. I have a bit of a headache; my right hip is at about a 1 on my pain scale. My left hip is at a zero today.

I am not nervous per se. Mostly I sense the culmination of an odd feeling I've been having all week, ticking off my "lasts" before the long period of recovery I will have ahead of me. Last tennis match, last day in the office, last subway journey, last night in my own bed in NYC, last walk with the dogs at my parents', last time driving a car (although the 3.5 hour drive up to Boston may have lessened the blow of that particular "last"). Today I will walk into that hospital feeling healthy and strong, carrying my own things, pushing through the revolving door myself, and bounding up the stairs to admitting in what will be my last "bounding" for a long while. It is quite a juxtaposition with how I'll be in half a day's time.

But my hips are built the way they are built; this surgery is a necessity. People have more complicated, emergent, painful, dangerous, experimental surgeries every day; some come out with outstanding results, some come out with complications, some don't come out at all. I have done what I could to prepare for this, I have chosen a fantastic surgeon and an excellent hospital; there is nothing more for me to do now other than trust the experts. The ball (of my hip)* is in Dr. Millis' court now.

*(Sorry, I just couldn't resist.)

Pre-op Appointments

Yesterday I had my pre-op appointments in Boston with the various hospital departments and Dr. Millis' team. Everything is now go-for-launch.

It was quite a full day, especially since my mother and I drove up to Boston and back to Connecticut the same day. Seven hours in the car plus five hours at the hospital minus one pint of blood equals exhaustion.

ADMITTING

First appointment of the day was with Inpatient Admitting. I met with a nurse who did (another) full history and vital signs, and discussed the surgery process with me. Not the actual surgical procedure, but the process surrounding the surgery.

On the day of the surgery I am to arrive sans jewelry, colored nail polish, tampons... basically nothing foreign on or in my body. Last meal must be 8+ hours before surgery (so basically dinner the night before). The nurse advised me that one should make sure one is not constipated coming in to the surgery because one gets more constipated from the anaesthetics. Also best not to have a big meal the night before because you will regret it when you wake up after surgery and throw up everywhere because you ate too much the night before.

After the surgery I will go to recovery and then my room. They can't promise me a private room since I am a low priority for a single room (i.e. I am not carrying an infectious disease or something of that nature) but they told me they would not put me with a child. Even though it is a children's hospital they do treat adults (obviously) and so I'll get an adolescent or an adult roommate, if I have one.

Admitting is the department I go to for check in on the morning of my surgery. Since my surgery is scheduled for 7:30am, I will get to admitting at 6am and they will make sure I have followed all the guidelines above. They will also check vital signs and blood before sending me to the surgical floor.


ANAESTHESIOLOGY

I met with a member of the anaesthesiology team, but he is not necessarily going to be my anaesthesiologist on the day. We discussed my options, which were basically general anaesthesia and a) epidural or b) PCA ("pain pump," where you administer your own pain medication by clicking a button on your IV line). I chose epidural because I'd rather have a steady flow of medicine from pre-surgery through recovery than having to pump my own medication and get "behind" on the pumping while sleeping, etc.

The epidural is inserted pre-surgery (but post administration of sedation and pain medication such that I am not really conscious of the epidural insertion). After the IV line is put in and I'm on relaxy meds, I will have to lean forward and make my back into a C, like in Pilates. That opens up the spaces between the vertebrae and makes it easier to get the epidural in. They assure me it won't hurt very much at all, but if the actors on Grey's Anatomy are anything to go by, that is a big fat lie.

Once the epidural is in, I will be put completely under with general anaesthetic, my breathing tube and urinary catheter will be inserted and the games begin.

After the surgery I will come to in the recovery area and will apparently be very thirsty and dry of mouth, due to the breathing tube having let my entire mouth/throat system dry up throughout the surgery. I will also apparently be nauseous (hence the light meal the night before).

The epidural stays in for three days, after which I will be switched to whatever oral cocktail of painkillers works best for me for the remainder of my stay. The hospital has a "pain service," as the anaesthesiologist put it, so my medication can be increased/adjusted 24 hours a day, whenever I need it.


INSURANCE

In pre-op admitting, you sign most of your necessary consent forms so you don't have to do it the day of the surgery. Consent/understanding of risks for anaesthesia and the surgery itself, naming of a proxy in case you can't make decisions on your own (gulp), acceptance of financial obligation if insurance doesn't pay for your surgery.

Insurance itself is, for now, a non-topic. My insurance (Blue Cross) has covered everything so far, and apparently the hospital's insurance department has already begun the process of getting my surgery approved and covered. They'll get in touch if they need me. So no news is good news in this department, I suppose.


BLOOD DONATION

During pre-op admitting, one is usually sent to the phlebotomist for some blood work, but because I was also doing an autologous blood donation yesterday I only had to get stuck once for both pint and vials.

On February 9th I gave my first autologous blood donation at the New York Blood Center in New York. I'd never given blood before because I always feared that my horrible, very bad, no good veins would be even worse if you tried to squeeze a pint of blood out of them. At the New York Blood Center, I was wrong. The guy found a vein somewhere in the marble blankness of my arm, got the line in with minimal pinch, and the blood came out so fast that I felt quite unwell and nearly passed out.

At Children's Hospital blood center, it was a different story. When I got to the blood center, my blood pressure was apparently 80/60, which is pretty low (standard is 120/80), and my nurse was concerned and told me to pound a bottle of water and try again. The next measurement was higher, though, and so the attempts with the needle began. The girl got a line in, but the blood was coming out SO slowly. And she had to keep moving the needle in the vein to restart the blood flow when it waned. Needless to say it was highly uncomfortable. Although the plus side of blood dripping out of me slowly is that I didn't practically pass out from the blood loss like I did in New York.

I have one more autologous donation on March 2nd in New York and then I am done. Hopefully I will get Mr. Expert again; I'll take a little syncope over a needle-wiggling drop-by-drop eternity any day.

When I donate in New York, it is shipped up to Boston. I had to donate at least one of my three pints on location in Boston, because it needed to be separated into platelets and plasma right away for concentrated injections during surgery. Shipped blood apparently cannot be separated in the proper way.

At my first blood donation, my iron was 14.6. In Boston yesterday it was 12.5, even though I'd been taking iron supplements in between the donations. Twelve is a normal reading, so I am not low, I just need to continue with the supplements and the iron-rich food through the next blood donation and up until the surgery.


PHYSICAL THERAPY

I met with the physical therapist who will be working with me during my week in the hospital, and monitoring me during my recovery. She taught me how to walk on crutches, which was not really new considering I was on them for a month just a year and a half ago for the tennis injury. I remember them all too well.

The physical therapist said I should expect to be on crutches for three months after the surgery. I have heard varying reports from other women who have gone through this surgery, so it is clear that the length of time one is on crutches (as well as every other variable in this process) is highly individual and contingent, and so difficult to predict with any useful accuracy.

I was also told I needed a special raised toilet seat, a shower chair and a wheel chair. Honestly, I can't see myself ever using the wheel chair, since my parents' house and environs are not very conducive to wheeling rather than crutching. I am most likely not going to have a CPM (continuous passive motion) machine unless there is work done on my femoral head. I will do a more complete list of "things I need" in another entry.


SURGICAL TEAM

Last but most importantly, I met with the surgical team, which is to say Dr. Millis, Dr. Prashant (who I'd not met before but I assume will be scrubbing in) and Erin Dawicki.

We went over the whole morning-of-surgery procedure that I'd discussed with admitting and anaesthesiology earlier in the day. Dr. Millis explained that depending on how it all looked in there when he opened me up, he might need to fix any tear there might be in my labrum or do some shaping on my femoral head if it is needed to help the (newly aligned) joint fit together properly.

Dr. Millis also discussed my left hip. It seems we are going to have to do the left as soon as possible after the right. I recently had some significant pain in the left hip (only) during a walk, which was unusual because it is usually my right hip that hurts first, most, or at all. And when I was on crutches a year and a half ago, my left leg was my "good" leg and took most of my body weight for a month, resulting in severe pain. I am quite certain that as soon as I start crutching around after my right hip PAO, my left hip is going to start complaining loudly. But we shall cross that bridge when we come to it.