Category: Medical Procedures

What It’s Like to Have a Surgical Screw Removed

Before my wrist surgery, I did research.  The medical journal articles all said that standard protocol for scapholunate repair was to leave in surgical screws no more than 12 months.  My surgeon said, “We’ll see.  Sometimes we just leave it in there.”  A long discussion ensued.  Post-surgery, the conversation continued.  At each post-surgery follow-up, we discussed the screw.  X-rays continued to show that the screw was not moving – it was stable.  The wrist healed well.

However, about 18 months later the wrist began to ache.  There was pain with basic actions.  The wrist would throb, and I would ice it in the evenings to get some relief.  At the next follow-up, x-rays showed that the screw was loose and had possibly migrated a bit, so that it was possibly impinging on an adjacent bone/nerve.

The surgeon went from “We’ll leave it alone as long as it’s not causing problems” at previous visits to “That’s it!  It’s coming out.”  “How soon do you want to schedule the surgery?” I asked, thinking he’d say “No rush, what would work with your schedule?” and we’d find a date in the next six months.  “Tomorrow?” he joked, following up with “As soon as possible – within the next month.”

“Ok, it hurts, but what’s the hurry, doc?”  “Well, besides the pain it’s causing, it would be really bad if you fell – bent or broken screws are bad.”  So I had to ask, “Yeah, how *do* you remove a bent screw?  Do you have to cut it into sections and remove each section separately?”  To which he replied, “If it’s bad enough, sometimes we just have to leave it, because we can’t get it back out.”  Yikes!

Needless to say, I was very cautious leading up to the surgery.  Fortunately, I avoided damaging the screw.

Surgery went very smoothly, although the surgeon threw me a curveball in pre-op.  He suddenly informed me that if the hole left by the screw was larger than desirable, he’d like to fill it with cadaver bone.  He knows I research every action thoroughly, so I was a bit stressed by this last-minute information, which would lead to a less-informed decision than I prefer to make.

Although I have no problem with the use of cadaver bone in general, I decided not to exercise that option for myself because my body is hypersensitive and overreacts to substances most people can tolerate, like fragrances and chemicals.

When I reminded my surgeon of that, he told me that another option would be to use my own radius bone as a donor by shaving some bone from the radius and inserting it into the hole in my scaphoid and lunate bones.  This sounded like a much better option for me, given that I cannot even tolerate the adhesive on band-aids on the outside of my body.  So that is what he did.

Hardware removal is typically a quick and easy procedure.  Since all they were doing was removing a screw from my wrist, the anesthesiologist used a lighter anesthesia, and did not do a nerve block at my neck.  He did use some type of local anesthesia at the site, because my thumb was numb for about 12 hours afterward.

My orthopedic surgeon removed the screw arthroscopically.  He did not like the size of the hole left by the screw, so he removed small pieces of bone from my radius and packed them into the hole.  Then he stitched the incision closed and my wrist was wrapped in a soft cast.

I wore the cast for two weeks.  My arm itched like crazy*, so I kept the arm iced for two weeks, which gave me relief from itching and from pain.  [I used a re-useable cold pack, which we placed in a zippered pillowcase to protect my skin and to keep the ice pack from sliding around as much.]

[*I was probably having an allergic reaction to the soft cast.  If I had experienced additional allergy symptoms beyond itching, I would have called my doctor’s office and informed them of the problem and asked about possible alternatives to the soft cast.]

I did not experience much pain.  There was a dull ache for the first few days, and my wrist would hurt as it became fatigued.  I treated the pain with Tylenol and frequent icing.  I also kept my wrist elevated above my heart and propped my wrist up on pillows whenever possible.  I also slept with my arm in a sling, as ordered, and propped up on a pillow.

So, basically, the formula RICE [Rest, Ice, Compression, Elevation] worked well for me.  [The soft cast partially consisted of compression bandages.]

Two weeks post-surgery, I went for a follow-up visit, at which time they removed the cast and the stitches.  The doctor applied a few steri-strips over the incision site and gave me a wrist splint to wear for another 2-4 weeks, including while I slept.

They also took x-rays to see how the healing was going.  I could see the hole in my bones where the screw had been, the metal clip the surgeon used to reattach my scapholunate ligament in my first wrist surgery, and the area where bone was shaved from my radius.

My surgeon had asked if I wanted to keep the screw [he knew I would].  Of course I said yes.  So after the screw was removed it was sterilized, and they returned it to me at the two-week follow-up:

My surgical screw (a.k.a., the loose screw)

Unlike my first wrist surgery, after this surgery I had a lot of bruising and discoloration.  Initially, my thumb turned dark purple, almost black.  I did the press test (a.k.a. capillary nail refill test) on my thumb nail and the blood flow was fine, so I just kept a careful eye on it for a few days.  Fortunately, after a few days my thumb stopped getting darker, and started turning the green of a healing bruise.

Once my cast was removed I could see that my hand and wrist were bruised too.  The surgeon said the bruising was mostly due to having shaved bone from my radius.  If I had chosen to use cadaver bone, I probably would have had much less bruising and less pain.

At the two-week check-up I was cleared to drive and to get the incision area wet, but I was given a weight-lifting restriction of 2 pounds or less.

Six weeks later (eight weeks post-surgery) I had another follow-up with my surgeon.  He (and  I) were very happy with how the incision was healing.  X-rays were taken again, and we could see that the bone graft was filling in the hole left by the removal of the screw.  However, I had noticed that my wrist and hand were weak and that I was having tendon pain in my anterior (palm-side) wrist and in my lateral (outside) elbow.  The surgeon confirmed that my tennis elbow had returned, but didn’t have an explanation for why the inside of my wrist would be hurting.  He recommended that I do some gentle exercises at home and give it more time to heal.  He also increased my weight-bearing limit to 5 pounds.

Although I had stopped wearing the wrist splint approximately 5 weeks after surgery, I decided to start wearing it again in order to give the wrist more support and more time to heal.  After about a week (nine weeks post-surgery) I didn’t feel like I needed it anymore, but wearing it for that week had taken strain off the sore tendons and they were feeling much better.

My final follow-up with my orthopedic surgeon was four weeks later (twelve weeks post-surgery).  The final set of x-rays looked good, and I was released from his care.

For those of you who are keeping score, the injury occurred in early 2014.  After four plus years and five surgeries to repair the damage (and remove my loose screw 😉 ), this appears to be the conclusion of that episode.

[Unless the tennis elbow requires another surgical correction.  My surgeon previously performed a tennis elbow release (a.k.a. lateral epicondyle release), but when I told him the elbow was symptomatic again, he informed me that sometimes scar tissue can form post-surgery and cause restriction, pain, or both at the surgical site.  Before I would have another surgery, I would try a cortisone injection and more physical therapy.]

The last surgery was the easiest one from which to recover, but I am glad to have that all behind me.  [Have you ever tried to blow your nose with only one hand?]

As I have already said several times, BEWARE SLIP-AND-FALL INJURIES!

BONUS: Anything you ever wanted to know about orthopedic hardware

Post-Surgery Status Update

Surgery went very smoothly.  It was a quick and relatively painless procedure [post pending].  I did not feel loopy or drowsy afterward, and had a perfectly normal afternoon following surgery.

Now that I have learned the benefits of frequent icing post-surgery, I use significantly fewer painkillers.  Don’t get me wrong – you should definitely use them if you need them!  I took painkillers at the minimum allowed interval for many days after my SLAP repair – that recovery was brutal.

But I have found frequent icing, elevation, and Tylenol to be sufficient for my last two surgeries.  However, it must be said that I have always had a high pain tolerance, which has increased even more after nearly two decades of migraines.

Manage your pain responsibly, and in the way that is optimal for you, in consultation with your doctor.

So now I’m in a soft cast for two weeks, and sleeping in a sling at night to protect my wrist – never comfortable or convenient, but a necessary evil.

I have to say I am incredibly grateful for arthroscopic surgery – it makes the procedure so much less invasive and the recovery so much easier.

I realized as I was in-processing for surgery that it has been four years since the initial injury.  I strongly hope that this will be the last corrective procedure, and I can finally put that incident behind me!  Beware slip and fall injuries!

WARNING: If your prescribed painkiller includes Tylenol (acetaminophen), do not take additional over the counter Tylenol (acetaminophen).  Pay close attention to daily dose limits.  Exceeding the daily maximums can cause liver damage.

I take Tylenol instead of prescription painkillers, NOT in addition to them.

 

Feeling like Ross Geller Again

Remember when I said my 2017 New Year’s Resolution was “No surgeries in 2017” – and then I had to have surgery?

Well, I was wiser this year.  I did *not* make a resolution of no surgeries in 2018, which is good, ’cause here I go again.

I met with my orthopedic surgeon yesterday and told him that my wrist is hurting again.  He took x-rays and informed me that the stainless steel screw in my wrist appears to have shifted a little bit, and also appears to be loose and moving around a little bit.

You can imagine the fun Spousal Unit is having with my diagnosis of a “loose screw.”

The surgeon wants to go back in and remove the screw, now that the wrist is stable and the tendons have had time to repair.  He wanted to do the surgery a few weeks from now, but I negotiated for a couple additional weeks – not because I like the discomfort, but because I’m still trying to finish grad school.  And also because I will need time for the authorization from Tricare to come through, which is apparently a hassle right now due to the contract changeover to a new contractor.

So why did I say I feel like Ross Geller?  Well, that’s Spousal Unit’s fault.  When I made the resolution to have no surgeries in 2017, and then needed surgery, Spousal Unit reminded me of the Friends episode in which Ross resolves “No divorces in ’99!” (See below):

So here I am.  Headed for surgery again.  Wondering if I should tempt fate by saying “Just the one surgery in 2018.”

Shoulder Surgery: The Good, The Bad, and The Ugly

To repair some of the damage done when I wiped out on that wet tile floor, I’ve had two shoulder surgeries – performed by two different surgeons.

The first surgery was to repair my severed labrum.  This injury is more commonly known as a SLAP tear.  SLAP is an acronym for Superior Labrum Anterior and Posterior.  The labrum is a ring of cartilage that surrounds the socket of the shoulder joint.  It helps to deepen the shoulder socket and to stabilize the shoulder, and is the attachment point for many of the shoulder’s ligaments and one of the biceps tendons.

Torn labrums are ridiculously painful.  Before I was successful in convincing  my PCM that I needed a shoulder MRI, I was taking strong drugs and begging for a referral to pain management.

My first shoulder surgery was also my first ever surgery – if you don’t count having my wisdom teeth out years ago.  It was pretty straightforward.  My labrum was severed; the surgeon went in and reattached it.  He used a couple of plastic anchor bolts and some sutures to reattach the labrum.  He cut away a little dead tissue, and made sure there was no other damage that had not been detected by the MRI/arthrogram.

Prior to the surgery, I had been in a ridiculous amount of pain.  I was able to sleep in one position on the couch – lying on my non-injured side, with my back against the back of the couch, and surrounded by 5-6 pillows that held my shoulder in the one position in which the pain mostly subsided and I could fall asleep.  Of course, anytime I moved in my sleep and the shoulder shifted, the pain woke me up.

Post-surgery was worse.  I didn’t get the memo that the best way to recover from shoulder surgery is to sleep in a recliner.  We did not *have* a recliner.  Had I known, I would have begged, borrowed, or bought a recliner.

Seriously, if you’re going to have shoulder surgery, make sure you can convalesce in a recliner – or an adjustable bed.

I came home from out-patient shoulder surgery narc’d to the gills (technical term) ;-).  Typically, for shoulder surgeries the anesthesiologist will do a nerve block, which blocks the nerve signals for up to 24 hours.  I was also placed under general anesthesia for the surgery.  And the nurses often will give you a narcotic before you leave post-op, to make sure you “stay ahead” of the pain.

So Spousal Unit got me back into the house and ensconced on the couch.  I got “comfortable” sitting sideways on the couch, with my newly repaired shoulder in a sling that was resting on multiple pillows and leaning against the back of the couch.  I dosed most of the rest of the day, and slept sitting up for the first few nights.  (Not comfortable.  Do not recommend.  You need to be exhausted to do it.]

I had a long and painful recovery.  My labrum hurt significantly LESS after surgery, but it still hurt like hell.  You have to keep your shoulder immobile for a long time to allow the labrum to heal, and that creates other problems, as your shoulder and elbow can get painfully stiff.

Flash forward two years, to shoulder surgery #2:

The shoulder felt “good as new” for about a year and a half.  And then it didn’t.  First the motion felt “off.”  The shoulder started to catch and clunk.  Then the pain started to return.

By this time, we had moved to another state, and I had a different orthopedic surgeon, who had already operated on my wrist and elbow.  After the manual examination and the MRI/arthrogram, he told me he would operate, but he wasn’t going to repair my re-torn labrum.

In fact, he told me that if he had performed my first shoulder surgery, he wouldn’t have repaired my severed labrum.

“Okay, doc, you HAVE my attention.  Please explain to me why you would not have repaired something that was totally severed and causing excruciating pain, because that sounds totally counterintuitive to me.”

We then proceeded to have a long conversation about labral tears.  And age.  In a nutshell, my ortho explained that labral injuries do not heal well in patients over 40.  Based on his experience and knowledge of the literature, he thought it was a waste of time to repair the labrum again.  Instead, he wanted to severe my (perfectly functional and not damaged in any way) biceps tendon from the labrum and reattach it to my humerus in a procedure called a “biceps tenodesis.”

The reason for this is that the biceps tendon is connected to the labrum, and the tension it exerts on the labrum can prevent the tear from healing and can actually make the tear worse.  By removing this tension, you create the possibility that the labrum might heal itself.  But even if it doesn’t heal, because you removed the stress on the labrum, hopefully the tear won’t continue to get larger.

My surgeon recommended I read a couple medical journal articles on the subject (because he knows I always thoroughly research my medical issues and the procedures doctors recommend to treat them), and then we would meet again to discuss the surgical options.

Here are some of the articles I read to inform my decision about revision [repeat] shoulder surgery:

“Controversy persists about whether to repair SLAP tears in patients over 40 years with associated rotator cuff tears (RTC).”

Torn rotator cuff with SLAP tear

The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs

“The cumulative evidence supports labral debridement or biceps tenotomy over labral repair when an associated rotator cuff injury is present.”

Subpectoral biceps tenodesis for the treatment of type II and IV superior labral anterior and posterior lesions.

Glenohumeral ligaments

Superior labrum anterior posterior (SLAP) tears

Rotator cuff injury

There’s a good quick-and-dirty summary of the research here, which answers the question: “Why would you fix my biceps if my labrum is torn?” It also provides a good explanation of the procedure and has an illustration.

The research supported what my ortho had said.  In fact, in recent studies labral tears were shown not to heal well in patients older than 26.  26!  In addition to the SLAP tear, the arthrogram had shown a small rotator cuff injury, and the research on that injury recommended repairing the rotator cuff, doing a biceps tenodesis, and leaving the torn labrum alone.

Had this been my first experience with this surgeon, my decision might have been more difficult.  But, based on the research, and based on my previous (all excellent) experiences with this surgeon , I decided to trust him to fix my SLAP tear by ignoring the labrum and jiggering with my biceps tendon.

I felt really uncomfortable letting him cut something that wasn’t broken to begin with.  In the end, you do your research, make the best decision you can, and trust your surgeon (whom you have carefully researched and selected) to do a good job.

Fortunately, when he got inside my shoulder, he found no evidence of rotator cuff damage, so he inspected it thoroughly and left it alone.  Had I needed rotator cuff repair, my recovery would have been much longer.

I was a lot smarter the second time around.  I had a recliner AND an adjustable bed.  Never even needed the recliner – the adjustable bed worked just great!  I was able to raise the head to get enough support for the shoulder, but still be able to sleep.  I still propped up the arm on several pillows, but got much better quality of sleep than the first time around.

But here was the absolute game-changer: a chiller (aka cold therapy).  Now, faithful readers of this blog will know that I seldom endorse any product.  But a post-surgery chiller is something I HIGHLY recommend.

I don’t know how I didn’t know about them before, but these devices circulate ice water over the site of your injury/surgery.  This helps prevent inflammation, and also brings pain relief.  Chillers are particularly useful for joint surgeries (shoulders, knees, ankles, etc.)

I was offered the use of a chiller by some folks at church, because Tricare would not provide one.  [Possibly because my surgery was through a civilian provider.  I have recently seen military facilities loan them to patients post-surgery.]  They come in various sizes.  I was loaned a pretty basic one (see image), but it worked just great.

I understand that the folks I borrowed it from keep an eye open at thrift stores, yard sales, etc., and pick them up pretty cheaply.  Then they have one when they need it, and one or two to loan out.  It certainly made my recovery quicker and much less painful, and I am grateful.

[For the curious: Yes, it’s basically a small ice chest, but it has a pump and hoses that circulate ice water around the injury.  At the end of the hose is a plastic pad (see image) that you wrap around the injured site.  You can secure it with an included velcro flex strap (like an ace bandage).  All you have to do is add ice and water and plug it in.  BE CAREFUL TO AVOID COLD INJURIES.  Don’t ice for more than 20 minutes at a time, remove if it’s uncomfortable, and always place something between the pad and your skin (a hand towel, washcloth, pillow case, etc.).  ]

Why I am in love with cold therapy: After my first shoulder surgery, I was prescribed narcotics – “Take 1-2 pills every 4-6 hours, as needed.”  They wore off after TWO hours, and the pain was overwhelming.  I was living from dose to dose, just trying to hang on.  After my *second* shoulder surgery, I was given the same prescription, but I also used cold therapy.  I took 3 pills TOTAL.  And the second and third were only because the staff had given me multiple warnings about staying ahead of the pain, and I knew from previous experience that I did NOT want the pain to get ahead of ME.  I didn’t think I needed the narcotics, but was afraid to rely on the machine for pain control.  But as I increased the interval between pills, taking them only one at a time, and found that I was able to control the pain with cold therapy, I stopped taking them.  (The other great thing about that is, if you’re not taking narcotics, you don’t get opioid-induced constipation.)

Was the first surgeon wrong?  He repaired the damage, did a pretty good job, and it worked great for about 18 months.  He did no further damage, scarring was almost non-existent, there were no complications, and he didn’t overlook or fail to repair anything else.  My biggest complaints would be that 1) he did a repair that the research clearly shows to have a high failure rate in patients my age.  So I question how current he is in his knowledge of the literature in his field.  And 2) I did not have to suffer as much as I did post-surgery.  I really wish he’d told me about the chiller and the benefits of recovering in a recliner.

Had I seen my second orthopedic surgeon first, I probably would not have needed the second shoulder surgery.

Bottom line: The first orthopedic surgeon was adequate, but probably not as knowledgeable as he should have been.  There is a world of difference between surgeons, even between an *average* surgeon and an *excellent* one.

The Good: Cold Therapy/Chiller.  Adjustable bed/recliner.  An expert surgeon.

The Bad:  Needing revision (repeat) surgery.

The Ugly: The excruciating pain after my first shoulder surgery.  Sleeping sitting up on the couch.  Trying to take a shower after surgery (once cleared by the surgeon).

I did a lot of research before my first shoulder surgery.  I avoided a truly horrible surgeon, and selected one based on research and recommendations.  There was still a lot I didn’t know I didn’t know.  

Stay tuned for blog posts on how to select a specialist, such as a surgeon.  Knowledge is power.

 

“Where Did You Take Your Urine?”

I’ve been getting diagnostic testing done to determine whether I have an autoimmune or autoinflammatory disorder. So far, some abnormal test results, but no diagnosis.

I had a follow-up appointment with a specialist today.  [I was hoping for a diagnosis.]  We were supposed to go over the test results. However, not all of the results have been returned to the specialist. The 24-hr urine collection sample had to be sent to the Mayo Clinic because they have the only lab in the US that can do some of the tests I needed.  And the results are M.I.A.

My doctor left the exam room, and returned with her nurse, saying, “This is my awesome nurse, [NAME].” I said, “Hello, awesome nurse [NAME]!” The nurse smiled, and responded, “Where did you take your urine?”

And even though I understood she meant, “Where did you deliver your urine sample, so we can start tracing it and hopefully get the test results?,” I couldn’t help but pause before responding, because what I was thinking was, “Now there’s a sentence I’ll bet you never thought you’d say before you became a nurse!”

And I also had to resist the urge to respond sarcastically with a list of all the cool places I had taken my urine: amusement park, carnival, swimming pool…

Once my inner dialogue had run its course, I responded with the name of the lab near my home to which I had delivered my specimen, so that they could ship it to the Mayo Clinic.

Hopefully we will be able to track down my test results.  I would prefer not to do the 24-hr collection again.

In the meantime, here’s hoping no one asks you: “Where did you take your urine?”

Breaking My New Year’s Resolution: There WILL be surgery in 2017

The plane in this photo is ground looping.  A ground loop can happen when a plane rotates horizontally (slides) while on the ground.  Ground loops can damage the landing gear, underside, and wings of an aircraft.  If a wingtip digs into the ground, the plane can even cartwheel.

Having ground looped my body three years ago by slipping on a wet tile floor and catching a wing (left arm) violently, I find that I am still not fully repaired.

I had hoped that the elbow surgery would be the last required repair.  However, we did not see the results we had hoped for.  The elbow surgery was a success, but I still had symptoms.  Distressingly, the shoulder (which was the first item repaired) was clunking again, and beginning to hurt.  It no longer functioned normally.

After failing physical therapy again, and undergoing an arthroscopy and MRI for said shoulder again, I learned that the first surgery (in the words of my current orthopedic surgeon) had “failed.”  The labrum showed a recurrent tear.

My surgeon informed me that he would not have performed the first repair in the manner in which my previous surgeon did, because I was “too old” for the surgery to be successful.  I might have thought about being offended at the age remark, but my surgeon is just a year or two younger than I am.  However, I was a bit irked that my first surgeon apparently wasn’t as current in the research as my second surgeon.

I was informed that labral repairs were previously thought to heal successfully in patients in their forties, but that more recent research shows the labrum doesn’t heal very well in patients much above 30.  For example, “A systematic review of surgery for SLAP tears included several studies that reported higher failure and complication rates in patients over age 40.”]

Because, of course, that couldn’t be enough, the MRI also showed that one of the tendons that comprise my rotator cuff is now torn also, as is one of my glenohumeral ligaments.

“See Doc, I told you it was broke!”

So now I’m headed for my fourth surgery to repair the damage done when I slipped and fell on that blasted wet floor.  Shoulder, wrist, elbow, and now, shoulder again.

It remains to be seen whether the rotator cuff tendon is torn enough to warrant repair, or whether it can be left alone to heal by itself.  If the surgeon needs to repair the rotator cuff while he’s in there, the recovery will be much longer and more painful.  [If the rotator cuff needs surgical repair, my projected recovery time doubles.]  So I’m hoping the rotator cuff damage isn’t too bad, and he can leave it alone.  The surgeon will probably leave the glenohumeral damage alone too.

It’s disillusioning when you discover that some damage just isn’t worth repairing – you’ll either heal or you won’t.

I know this sounds like maybe my current surgeon just doesn’t want to exert himself, and maybe I should be concerned for my welfare.  But I can reassure you (and myself) that this surgeon is one of the best.  I heavily vetted him before I let him operate on my wrist, and that surgery was phenomenally successful.  He also performed my elbow surgery, which had a successful outcome as well.

*Because* of our previous history, I am willing to trust him with my shoulder, even though what he is recommending sounds a bit counter-intuitive to me.  Even so, I am heavily researching his proposed surgical plan.  He knows that I do extensive research, and has suggested several relevant medical articles for me to review.

I am also aware that many orthopedic surgeons specialize in one area (knee, wrist, hip, shoulder, etc.).  Just because he is one of the best hand surgeons does not necessarily mean that he is a good shoulder surgeon as well.  He and I have discussed this, and I asked him how frequently he does shoulder surgeries, and what his success rate is.  I was satisfied with his answers, and I believe he will do as well with my shoulder as he has with my wrist and elbow.

So, I’m scheduled for shoulder surgery in about two weeks.

I’m really not looking forward to not being able to drive.  Or trying to wash myself with only one hand.  Not being able to open jars (and many other things).  Wearing pull-on pants, because I can’t fasten buttons.  Wearing slip-on shoes, because I can’t tie shoelaces.  Don’t EVEN get me started on how impossible it is to open the safety cap on prescription medicines with only one hand!  (Shouldn’t the pharmacy get notification that the prescription is for a patient who won’t be able to open the medicines if they flip the lid to “Safety”?)

But every time I go through this, it reminds me that my injuries could be worse.  That my disabilities could be worse.  I think a lot about wounded warriors when I am doing my rehabilitation.  My struggles will hopefully only be temporary.  Many wounded warriors live with their disabilities for the rest of their lives.

So many of the things we take for granted are a struggle for those who are incapacitated.  Health and able-bodiedness are the ultimate privilege.

Bottom Line:  I am scheduled for another surgery to repair my damaged arm.  My New Year’s Resolution of “No Surgeries in 2017” will be broken.  This will be my fourth surgery on this arm, and my second surgery on this shoulder.  I don’t know how many procedures the surgeon will need to perform during the surgery – I’m hoping only one.  I welcome whatever good will you’re inclined to send my way – hopefully the universe is listening.

I’m ready for the repairs to be complete and to be “airworthy” again.  I’m tired of living with the lingering damage from this ground looping incident.

WARNING: BEWARE SLIP AND FALL INJURIES!

Standing By to Stand By (And What It’s Like to Do a Spirometry Test)

I saw the specialist at a leading institution last week.  (Not the doctor in the picture, who is a random allergist/immunologist.)  It went about as well as can be expected.  But I don’t have any answers yet.

The specialist sent me for more testing.  More blood samples.  More urine samples.  (This will be my third 24-hr urine collection.)  Some tests are repeats (for verification).  Others are new.  One of the blood sample vials went directly into a bag filled with ice, since the component being examined is highly heat-sensitive.  First time I’ve seen that.

While I was at the leading institution, I also had a spirometry test.  This test measures how well your lungs are working.  It measures how much air you inhale and exhale, and how quickly you exhale.

I didn’t quite grasp how the test was supposed to work at first.  The assistant handed me a nose pincer that looked like two ear plugs on the ends of a clamp.

These are used to keep any air from escaping through your nose.

Then the assistant handed me the hose (with attached mouthpiece).

(I did not get to look at the display as the person in this image is doing.)

I was told to put the nose pincers on my nose, get a good seal on the mouthpiece, and exhale for 6 seconds.  This is the part that I did not understand.

I thought that if I needed to exhale for 6 seconds, I needed to pace myself. So I was gradually exhaling.  Apparently this is incorrect, because the test also measures how quickly you exhale, and I was told to exhale as hard as I could.

The assistant guided me through breathing “normally” through the mouthpiece for several cycles, then told me to take a deep breath, exhale hard, and keep exhaling until I was told to stop.

After a forceful exhalation, I didn’t feel like I had enough air left in my lungs to keep exhaling for 6 seconds, which is what I told the assistant.

I was told to keep a good seal with the mouthpiece and keep exhaling until told to stop, regardless of whether I felt anything was coming out.

We needed 3 good cycles of measurement.

On the first cycle, I exhaled hard and exhaled some phlegm.  I tried to keep exhaling without sliming their machine.  This may have compromised my performance.  (Didn’t mention this to the assistant.)  (Mouthpieces are sanitary, and are swapped out between patients, in case you were wondering.)

On the second and third cycles, I exhaled hard, and then felt like I ran out of air quickly.  I gave my best effort at exhaling for the entire 6 seconds, as the assistant was shouting, “Keep exhaling!  Keep exhaling!”  But I felt like no air was coming out.

Also, the nose pincers were sliding around on my nose, and I was concerned they would slide off, which was distracting.

Overall, the test was not difficult, nor was it painful or uncomfortable in any way.  You just sit in a chair and blow into a tube.  It is not difficult to inhale or exhale through the device.  It does not constrict your breathing.

But I thought I had failed the test.  I thought I should have been able to exhale noticeably the entire time.

Imagine my surprise when I was told that my “expiration” was better than normal!

This means that I probably do not have asthma, COPD, or other breathing conditions.  (I was not expecting to have any of these conditions, although it could have been possible to have allergy-related asthma.)

So today I am doing the 24-hr urine collection, and waiting.

I have a follow-up with the “expert” specialist in 8 weeks.

The specialist also gave me a prescription for another medicine to add to the ones I’m already taking.  If Tricare will approve the prescription, I can see how that works, and report back to the specialist at the follow-up appointment.

Bottom line: Saw the specialist.  Was told my hypothesis was worth exploring.  Was also told my symptoms are very difficult to diagnose, and we may never reach a diagnosis.  But the specialist is interested in helping me improve my quality of life.  The tests that were ordered make sense for an exploration of my hypothesis, and so does the new prescription.  The specialist was knowledgeable and empathetic.

So I am currently standing by to stand by.

Medical Procedures: Trigger Finger (Steroid Injection) Update

Update: I developed trigger finger in the same pinky finger approximately 10-11 weeks after elbow surgery (approximately 8 months after the first steroid injection), when the post-surgery therapeutic exercises began to put more strain on my finger.  I mentioned to my occupational therapist (OT) that my pinky finger was swollen and stiff, and that the joint near the top of my palm (the metacarpophalangeal joint) was very tender, sore, and warm to the touch.

My OT remembered that that was the same finger in which I had previously had trigger finger, and made an appointment for me with my orthopedic surgeon to get another steroid injection.  My ortho injected the joint approximately 12 weeks post-surgery, and said that if trigger finger comes back a third time, he would consider a surgical treatment.

Hopefully this will not be necessary, as my third New Year’s Resolution, which I did not share with you, is “No Surgeries in 2017!”

Ending 2016 with More Surgery

I am headed for surgery on December 14th (Wednesday).  This time for the elbow.  We’re not sure what’s wrong with it, exactly.  The symptoms are obvious, but the exact diagnosis is not. [At least, to me.  My surgeon might disagree, but then perhaps he should explain things better.]

The elbow hurts (all the time), and does not want to fully extend.  It would catch before the arm reached full extension and wouldn’t go any further.  Sometimes I could eventually get the arm to fully extend after multiple attempts.  The doctor gave me a steroid injection in the elbow joint, and now I can fully extend my arm (very slowly, and I have to wait for it to clunk into place).  None of the other symptoms were cured by the injection.

There is also a great deal of crunching and popping when I extend my arm.  The confusion lies in the fact that my elbow area snaps upon extension.  My surgeon thinks that I may have a snapping triceps, but that is supposed to happen upon flexion, although this journal article says it could happen in either direction.

Elbow 101: This website explains the basics of elbow anatomy and function.

My hand is also still swollen, with some numbness and lack of strength.  February will be three years since the original injury.  My hand has been swollen for nearly three years.  It is also discolored – compared to my healthy hand, it looks bluish-purple and darker.  The forearm does also.

The MRI resulted in a diagnosis of “tennis elbow” (lateral epicondylitis).

The EMG/CNS was inconclusive.  Based on my symptoms and physical examination, the surgeon is planning to do two or three procedures: 1) percutaneous tennis elbow release; 2) transposition of the ulnar nerve; and possibly 3) correct the snapping tendon if it is, in fact, snapping.

Here are explanations of the three procedures:

Explanation of percutaneous release from Cochrane.org:

Surgery on your elbow can include making a small cut in the arm and trimming damaged tissue from the tendon that joins the extensor carpi radialis brevis (ECRB) to the bone in the elbow (called an ECRB tenotomy), or releasing the tendon from the bone with a scalpel (called an ECRB release). The tenotomy may be done ‘percutaneously’, with a much smaller (1 cm) incision in the skin, or arthroscopically from within the joint.

Transposition of the ulnar nerve (Hughston Clinic Orthopaedics):

The procedure is performed under general anesthesia or with regional anesthetic. The ulnar nerve area is located and cleaned with an antiseptic solution.  A small incision is made around the medial epicondyle and the surgeon will locate the ulnar nerve.

This nerve is then moved out of its location under the medial epicondyle and placed in a more superficial area on the front the medial epicondyle. This new position may be directly under the skin or may be within a muscle. This process of moving the ulnar nerve out of the groove under the medial epicondyle into the front of the epicondyle is called anterior transposition.

Transposition of the ulnar nerve remedies ulnar nerve entrapment.  There is another good discussion of ulnar nerve entrapment here.

This video includes a discussion of ulnar nerve transposition, as well as actual footage of the surgical procedure.  I don’t think it’s very gory, but if you’re squeamish, you may want to only watch the first part of the video.

The next video shows some footage from a snapping triceps surgery.  I think it is a bit gorier than the previous video, so you may not want to watch it if you don’t like the sight of blood and the inside of human beings.  However, I think seeing the internal mechanisms in motion is fascinating.

This surgery will be my third on this arm: shoulder, elbow, and wrist will all have been repaired.  At this point, I’m wondering if I should have opted for a bionic arm, or perhaps a robot arm like Luke Skywalker’s.  Again, I reiterate the hazards of slip and fall injuries!

Bottom Line: I will be NMC (not mission capable) through the end of the year.  I’ll let you know in 2017 how the elbow surgery went, and what the surgeon found when he looked inside.  

Here’s hoping 2017 is a year of increasingly better health for everyone.

Guest Post: What It’s Like To Try Acupuncture And Cupping

This week we have a special treat – a guest post from Doug Nordman a.k.a Nords, from The Military Guide.  He’s sharing with us his experiences with medical tourism.  He bravely (or foolishly?) underwent acupuncture, cupping, and moxibustion in Thailand.

Remember the Olympic swimmers and their purple dots this past summer?  That’s what you look like after cupping.  To learn more about these procedures, and medical treatment abroad, read on:

Thanks for inviting me to write about these treatments, Crew Dog!

I’m a 56-year-old retired U.S. Navy submariner. As a “recovering nuke,” I’m skeptical about alternative medicine. Before I believe in a medical technique I want to read a pile of peer-reviewed reproducible studies of double-blind experiments with statistically significant evidence– and acupuncture just isn’t there yet. If acupuncture achieves anything at all, it might be simply a gigantic placebo effect.

However I’ve lived in Hawaii for over 25 years, where Occidental and Oriental cultures overlap with science and technology. I’ve learned to keep an open mind when I encounter treatments which defy the explanations of medical research.

My physical therapy for joint injuries has taught me that Western medical science doesn’t always have a precise explanation for why a technique works. I’ll enjoy the results whether or not I fully understand the mechanisms. If acupuncture is simply just a gigantic placebo effect then I can live with that.

I’m also willing to try new approaches because I’m a little frustrated with my aging body. I’m encountering new limits in my maximum heart rate and recovery time. When I was in my 40s, I used to burn through the Navy’s physical fitness test and then go work out. These days, after that type of exercise I’m tempted to burn through 800 mg of Ibuprofen and take a nap. When I do a couple hours of heavy yard work, I have to be careful to maintain good posture in my knees and my back – I don’t want to end up in another round of physical therapy.

My body’s latest betrayal is my left shoulder (deltoid) muscle. Over 10 months ago I felt a small “pop” during a push-up set, and the next day I couldn’t raise my left arm above my shoulder. It slowly healed over the next six months but I kept re-injuring it. When we traveled to Bangkok, I still didn’t have full range of motion and I couldn’t put my left hand up behind my back. I was worried that I’d injured my rotator cuff and I felt like an idiot.

Thailand’s cost of living is incredibly cheap, and Bangkok’s major hospitals are a magnet for medical tourism. My spouse and I had heard about the Traditional Chinese Medicine Clinic of Hua Chiew Hospital, and we were happy to spend a few dollars to experiment on my deltoids.

Hua Chiew is definitely not practicing traditional Western medicine: the hospital takes walk-in patients. The lobby was a beehive of activity with a large waiting area by the cashier’s window. The clerk at the front desk explained (in English) that a typical acupuncture treatment would be less than 600 baht. (At 35 baht per dollar, that’s just over $17– and nobody asked us about insurance.) He entered our names into their computer system. We stopped by the next table for a quick health check of height, weight, temperature, and blood pressure before being sent up to room 504.

The fifth floor was quieter, with a few patients in the hallway and a family in the waiting area. When I walked into room 501’s open ward, it smelled like old cigarette smoke– and marijuana. (Hey, I have a training certificate from a 1980s Navy drug education class with a “test burn”.) I was greeted by an acupuncturist and an assistant who asked me where it hurt. A few minutes later the assistant was guiding me to an exam table.

“This won’t hurt a bit.”

I was asked to remove my t-shirt (which the assistant quickly hung on a hanger) and arranged on my right side with my left arm extended across a pile of pillows. While the assistant set up the privacy curtains, the acupuncturist came up behind me with a tray of needles and other tools. (Selfies were discouraged during this procedure, but I took photos afterward.) I turned my head to watch, but she politely asked me to relax on my pillow so that she could put needles into my neck.

She swabbed my skin with antiseptic and opened a package. Each needle was about three inches long with tiny coils at their gripping end, and they seemed very delicate. They must have been extremely fine and sharp because I could barely feel them going in– just a cool sliding sensation as she inserted them about an inch. My skin didn’t even dimple as she gently and quickly placed them from neck to elbow. A minute later I had a dozen needles sticking out, and she suggested that I should stay still. She even put two needles in the side of my left calf, explaining that there’s a nerve connection to the shoulder.

Then the assistant brought out a power supply and an electronics box. I later learned that this was an electrical muscle stimulation system, and the acupuncture needles make it easy to deliver the electrons directly to the injured area. She wrapped electrical wires around two of the needle coils and flipped a switch. My deltoid promptly started twitching gently, about once per second. After she checked the electronics display, she brought out an IR heat lamp and positioned that over my left shoulder. She said she’d check on me in 30 minutes and gave me a call button to push if I had any problems.

I stayed as still as I could despite being a human pincushion with my shoulder twitching like a frog leg in Dr. Frankenstein’s high-school biology class, while the lamp heated my shoulder (and the metal needles). It must have looked extremely uncomfortable.

A few minutes later I dozed off.

Judging from the assistant’s polite smile when she woke me up, this must happen a lot.

Well, technically my deltoid kept twitching while the rest of me had a very nice nap. When she turned off the machine, my entire shoulder relaxed.

She gently extracted all the needles that they’d inserted. (I kept count just to make sure.) I could barely feel the sliding sensation as they were removed, but there was no pain.

Then she picked up a tray of heavy glass cups, and I realized that I’d signed up for a bonus cupping session after the acupuncture.

Cupping

The assistant laid out a dozen cups of various sizes. They were each about 2”-3” tall and 1”-2” in diameter, made out of heavy glass. She rubbed a light coat of oil over my shoulder and back (to get a better seal).

Next she used her forceps to pick up a cotton ball and dip it in a liquid that looked like alcohol. Then she picked up a cigarette lighter, set the cotton ball on fire, and walked over to my shoulder.

An open flame. In a hospital. In a ward where there were probably oxygen canisters near more flammable liquids and oily skin. With a submariner who used to teach firefighting tactics at a training command.

I was not happy.

It turned out that the flaming cotton ball heated up the cups (and the air inside them). The acupuncturist briefly warmed each cup over the flame and then gently slapped them down on the skin that had held needles. As the air in the cups cooled and contracted, the suction drew the skin up into the cups and held them in place. A few cups were pried off and re-applied for a better seal.

As the skin on my shoulder and back was pulled up into the cups, I could feel a warm tingling as more blood was pulled up into my muscles. Several minutes later the assistant released all of the cups (with a wood tongue depressor) and wiped the oil off my skin.

The acupuncturist asked me to sit up and move my arm around. It was still warm from the treatment, and the deltoid felt particularly loose. I was happy to discover that I had much more flexibility and no pain. Wonderful!

When I checked my shoulder and back in a mirror, it looked like I’d lost a grappling match with an octopus. (This picture was taken an hour later.) The acupuncturist reassured me that the bruising would fade in a few days. In my case, the marks took nearly three weeks to disappear.

after-cupping

What happened to make my arm feel so much better?

According to traditional Chinese medicine, my body’s qi had been manipulated by the needles and the cups to bring more healing energy to my damaged deltoid.

Western medicine claims that my muscles had been stimulated by electricity, bringing more blood and lymph fluid to help repair the microtears. The heat and the cupping had brought even more blood into the muscle and skin, causing more bruising yet supplying more healing fluids. My body would focus greater effort on repairing damage in that area, which would also accelerate repairs to the deltoid muscle.

And, of course, the hour’s performance had kicked my placebo effect (and endorphins) into overdrive. No wonder I felt so good.

I’ll leave that debate to the doctors. Whatever happened during that hour, the pain relief (and the greater range of motion) was worth every penny of $17.

When I paid the bill at the cashier’s desk in the lobby, it was more like $16.75. My smartphone’s Google Translate software wasn’t much help here, but if you read Chinese or Thai then please feel free to share the details.

hua-chiew-invoice-and-patient-card

Followup

As I left the fifth floor, I was handed a small appointment card and admonished to return in three days for more treatment. My spouse and I got busy with other activities (there’s a lot to see & do in Bangkok) and we returned in nine days. When we walked in (still no appointment necessary!), the front desk checked our cards and started the routine again.

When I walked back into room 501 it still smelled like marijuana. I confidently returned to my treatment table, hung up my t-shirt, and laid down for an encore of my last visit. The setup went the same and I was soon bristling with acupuncture needles, but they didn’t haul out the electrical box.

This time the assistant unwrapped a couple small paper packages the size of a section of a Tootsie Roll. Later I learned that they held a dried Chinese herb called moxa, and I was about to experience moxibustion.

She poked two of the herb bundles on top of two of the acupuncture needles… and then lit them with her cigarette lighter. I immediately realized why the ward smelled like marijuana smoke, only it was burning moxa.

moxibustion

As she pulled the privacy curtains closed, she asked me to push the call button if my deltoid got too warm. I soon realized that moxa burns just like tobacco and it was heating up the acupuncture needles. Those, in turn, conducted the heat straight down to my deltoid muscle. I wasn’t exactly getting first-degree burns, but it was uncomfortably warm under my skin. I gritted my teeth and vowed to wait out the moxa.

It must have worked because I dozed off again. The moxa stopped smoldering in 20 minutes and the assistant followed up with the heat lamp for another 10 minutes. They removed the acupuncture needles and commented that my cupping bruises were sure taking a long time to heal, but that was the end of the session!

This time I only paid 525 baht ($15).

Long-term results

We’ve been back on Oahu for a couple of weeks, and my left deltoid is completely healed. It could be qi or it could be targeted electricity and heat therapy, but the results are undeniable. I’m back to pull-ups and push-ups and reaching up between my shoulder blades. I’m also doing more stretching and taking it a little easier with the multiple sets, but now I know what a local acupuncture clinic (or the placebo effect) can do for me.

Either way, I’m happy.

Crew Dog: Doug usually writes about Financial Independence and Early Retirement, and how he did it on a military salary, at the-military-guide.com.  He’s also the author of The Military Guide To Financial Independence And Retirement.

Have you been a medical tourist, or tried alternative medical procedures? What were your experiences like?  Comment below.