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.)

Pain Scale

There is, apparently, no objective pain scale to be found on the Internet. Instead there are many angry nurse blogs complaining that there is no objective pain scale. And that patients who are clearly not in agony still say "10" when asked what their pain is on a scale from 1-10.

In order to avoid confusion on this issue, below is the pain scale I will be using throughout this blog.* Maybe I will post it by my bed in the hospital so the nurses tending to me can also benefit from its clarity.

0 - No pain.

1 - Conscious of occasional discomfort in the affected area, but discomfort is tolerable and does not inhibit daily activity.

2 - More steady discomfort in the affected area, however still tolerable and not inhibiting of daily activity.

3 - Some pinching, throbbing or sharper spikes of pain in the affected area, perhaps causing a brief wince. Discomfort still tolerable but beginning to make you think about favoring that area while moving/bearing weight on it.

4 - Overall higher level of pain. Activity of the affected area limited in an effort to lessen pain. Mildly distracting but non-strenuous daily activities like talking and reading are still possible.

5 - Pain level has become distracting, causing irritability when talking, inability to concentrate on reading or other activities. You are definitely not moving/bearing weight on the affected area. Mild sporadic profanity begins.

6 - Now you are getting pretty pissed off about this pain. Where is the f'ing nurse?!

7 - Tears, gasps and desperate mewing in between sobs. Mommy evoked.

8 - Wailing and white knuckles. God(s) evoked.

9 - You begin to think you have chosen the incorrect hospital for appropriate pain management. Lawyer evoked.

10 - Someone has lit your body on fire and is now attempting to put it out by beating you with track shoes. (Flip-flopper.)

*I reserve the right to alter or amend this pain scale if it turns out that writing it while not in pain, pre-surgery, on a Friday afternoon after lunch, has led me to grossly underestimate and/or mischaracterize any or all of the aforementioned pain levels.

Last Tennis Match

Five days to go.

Tonight I played my last tennis match before surgery. This time last year I was playing tennis two or three times a week, and was in the process of signing up for the three leagues I played in last summer, including one that I captained all the way to Sectional finals.

In the last couple of months I've played tennis maybe once every two weeks, with mixed results in terms of post-match pain. The decrease in my tolerance for a vigorous tennis match has definitely been one of the most saddening manifestations of my hip problems. I am hoping this surgery will bring me back to the courts as frequently and as capably as ever.

That said, of course I played some of my absolute best tennis tonight. Always good to go out on a high note.

My preparations for surgery are pretty much complete. I am on track to tie up all loose ends at work by Friday; I am on my way to being packed for what I expect to be six weeks away from my apartment in the city. I have not bought any of the equipment recommended by many other bloggers -- the grabbers or the sock donners or the bath chairs. I figure I will get (a parent to get me) what I need if I need it. I already have crutches from hurting my knee two summers ago. So my bag is mostly full of books and lounge pants.

My hip pain has been pretty minimal these last few weeks. It comes and goes, sometimes not seeming related to my activity level. During tennis yesterday I felt discomfort in the back of my right hip, or maybe in my lower back on the right side as a result of some compensation for the right hip. I also felt a sort of soreness on the outside of my hip, which is unusual. And afterwards of course the anterior labrum (basically the front of my hip, right at the crease when I lift my thigh) gave me some pain, which was to be expected.

My left hip has also piped up with a few twinges in the anterior labrum a few times this week. But none of this pain has been at all severe -- usually about 1 to 2 on a pain scale -- so it hasn't inhibited my activity more than to warn me that I should think about easing up.

Mentally I've been mostly unaffected by next week's events, other than a gradually receding paranoia that I will suddenly be felled with a cold and all my preparations and planning will be tossed out the window as my surgery is postponed for months and months. But as the days count down and I remain healthy, even that worry is fading.

Two Weeks to Go

Today was my third and final autologous blood donation prior to the surgery. I was glad to see that my iron-rich diet and iron supplements had raised my hematocrit level to 13.4 for this donation. My blood pressure was low, though: 90/60. My blood pressure has been lower and lower at each blood donation. I'm not sure why, or if I should be worried about it.

In any event, today's blood donation was much better than my donation during my pre-op visit to Boston. Today I was at the New York Blood Center again and I had the same technician, Skip, as I'd had during my first autologous donation -- the guy knows what he is doing. The whole process is as quick, efficient and painless as puncturing a vein and draining a pint of blood can be, I suppose.

I have also learned my blood type as a result of these autologous donations -- I have B+, just like my mother. And my secretary, for that matter. Strange to think I have gone 29 years of my life without knowing my own blood type. Only 10% of the U.S. population has B+ so it is even better that I have three units of my own blood standing by during the surgery.

Today's autologous donation was the last preparatory appointment I had on the books prior to surgery. Now I just wait two weeks, continuing to keep as healthy as possible, and continuing with iron-rich foods and iron supplements to get my hematocrit back up in time for the surgery.

I also found out today that my insurance (Anthem Blue Cross) has authorized the surgery as "medically necessary," which is an important step in having the entire expensive procedure and inpatient costs covered. All the contact with the insurance company was handled by the hospital, so luckily I was spared much of the wrangling that some women have had with their insurance companies over this surgery. At least for the time being.

Staying Healthy

Now, in last few weeks before surgery, the most important thing for me to do is remain healthy. I have heard too many horror stories of girls who have gotten a cold right before their surgery date and have had to have the whole thing postponed. Best to avoid that if at all possible.

DIET

Of course I am eating a healthy diet. Lots of fruit, vegetables and lean protein, very little sugar and starch. I have completely cut out alcohol. I am also focusing on iron-rich foods, to help my blood bounce back between autologous donations. So that means dark green leafy vegetables, red meat, beans, etc. A quick Google search can bring up a more comprehensive list. Liver anyone?

I am also taking iron supplements in addition to my usual multivitamin, omega 3 and calcium. There is a lot of information out there about what supplement to take (or avoid taking) with what food to increase absorption, but I just can't be bothered with taking it all in and regulating myself so much. So I'm just eating as healthily and ferrously as possible, taking the supplements, and hoping it all comes out in the wash. Or absorbs in the wash, as it were.

I have to mention that iron supplements will unpleasantly affect your digestive system. And I will leave it to you to look up why that is and what you can do to ameliorate some of the problem.

EXERCISE

Since my hip has significantly been increasing in pain over the past six months or so, I have been decreasing my activity level to compensate. I can no longer walk for long periods around the city (like to and from work) or play tennis at the frequency I used to. I can eke out a match here and there, but I will pay for it the next day (or even towards the end of the match).

For the most part, I am not usually in much pain on a daily basis, but that is because I have curtailed my activity level so much to avoid aggravating my hips. I don't take (and have never taken) painkillers when my hips begin to hurt -- not because I have anything against painkillers, but because I just figured the pain was a signal that I should stop. This kind of hip pain is not pain you can "work through" like having sore muscles that warm up and loosen up; this is pain that gets worse the more you do. So I figured if I mask the pain to allow myself to do more, I am just going to pay for it in the end (or cause so much damage that I would need painkillers to do even routine things in life). So basically my "painkiller" is to stop moving around until my hips stop hurting. Which has meant I don't move around much anymore.

So with that backdrop comes the challenge of getting myself into surgery shape without causing myself pain.

For cardio I have been doing the bikes (seated and stationary). Elliptical hurts my hip. I also swim, since I am lucky enough to have a pool in my building. I usually hate swimming laps, but since I got a swimming armband and earphones for my iPod, the boredom is gone!

For strength training I have been doing weights (both general circuit training and a specific focus on the crutching muscles: lats, pecs and triceps) and some Pilates mat exercises that focus on the muscles around the hip. I also do some of the hip muscle exercises in the pool after swimming my laps.

To be honest, I've only really gotten serious about this pre-surgery health-nuttery since last week -- most of the PAO women whose blogs I have read started much earlier. But I was already in decent shape, with good muscle tone from regular visits to the gym prior to this pre-surgery frenzy. So I'm not starting from zero. I'll just have to do my best for the remaining 2.5 weeks!

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.