Archive for March, 2009

Praise for Water Above

March 9th, 2009

I sing loud praise for shower baths!

After weeks of pouring water over my head out of and into a sink, and then washing and rinsing every accessible body part with a cloth, I showered. My surgical staples and Aircast had combined to keep me wet only one body part at a time.

The experience of running water everywhere was grand, cleansing figuratively inside as well as outside. Even though I had to sit in a lawn chair like the maimed guy I am, I feel I am returning to the natural order of modern life.shower bath

As so much does though, this dug deep into my childhood to return with a memory in its teeth. I knew a subset of people who had never showered and never even covered their faces with a wet washcloth. They bathed but feared water on their noses and mouth. In my innocence, I freed them.

The summer of my 13th birthday, we had moved from the bottom to the middle of Virginia. I was pressed into service teaching swimming — to a group of elderly never-been-swimmers. It worked.

I was taking both Advanced Swimmer and Junior Life Saving courses. I then had a couple of hours to swim and dive in the man-made lake before my mother picked me up. Coincidentally, she was the director of the Red Cross chapter and kind of the boss of the bosses of the swimming courses. That became important because my swimming instructor knew her as the efficient and responsible RC lady and me as her like-minded son.

She asked me flat out if I would try to make the group of eight or ten elderly beginners a little less fearful of the water. It turns that this WWI crowd grew up in times and places where they did not swim. Moreover, after I agreed to try, my students told me that they were afraid of water, particularly covering their faces. They had never had their heads under water, even in the bathtub.

Of course, I was both too comfortable in the water myself and too naive to consider failure, so I went ahead.

My mother had been a water-safety instructor for many years. I used the lesson books as recreational reading. Yet, there was little about the current problem. There was the Ben Franklin trick of dropping a hard boiled egg in the water and telling the fearful student to retrieve it. Most people were willing to perform a narrow task like that and would bob quickly to do it. That not only gave them some confidence, but it got them to look underwater and got them ready to float.

We all seemed comfortable with each other. I was a nice young kid who had grown up around RC volunteers, many of whom were elderly. Most of those insisted after knowing me for awhile that I call them by their first names as well. I was not shy around people as old or older than my grandparents.

The short of it is that it worked far better than my swimming instructor anticipated. We splashed water on our faces and worked up to blowing bubbles with our faces in the water. They grabbed white objects in waist-deep water. They learned to float with kickboards and then do that with their faces down between their arms.

I was absolutely not prepared for the excitement that ensued. To a one, they were delighted. They said thing like it was a whole new element. A couple said it was like they had learned to fly. They felt liberated. They were very pleased with themselves.

If I could teach people something that made them feel that way, I would have loved to made a career of that. The contagious joy of that group was extraordinarily sweet and powerful.

I hadn’t thought of that summer in quite awhile. Today, sitting in the lawn chair shampooing and scrubbing away, I found that their faces and words returned. What is a simple empowerment to others may deeply satisfy us.

I sing in praise of showers.

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What Surgeons Were Thinking

March 8th, 2009

Self-absorption in post-trauma periods seems to be pretty human. I found myself with another spasm of it yesterday when my wife presented the medical report that had come from Brigham and Women’s following my arrival by ambulance and then leg surgery.

Not one to waste the medical proxy I had signed before anesthesia and internal carpentry, she had ordered the records. We got our $6.07 worth, copying and postage. In addition to my vital signs at various times and what drugs they pumped in me in the ER when jamming the bones into rough alignment was the Operative Report.

That section is a two-page recap of what they did and why. I think I’d be just as fascinated if it described someone else’s operation. I immediately began musing on what else we might like to see such details on. Consider:

  • Your flight into Logan airport makes a sudden 180 degree turn, returns low over the water and seems ready to touch down on the tarmac when it accelerates, rises again and comes back for the real landing. The pilot may mumble a “sorry, folks” quasi-apology, or not. Wouldn’t it be great to get an email saying what caused the abrupt and maybe crash-preventing maneuver?
  • You’re happily overpaying for an occasion meal. While chefs are famous for predictable reworks of their dishes, this evening’s special entrées are great in the mouth and to the eye, and unusual enough that you ask the waiter its ingredients. Wouldn’t it be better to get a little report from the chef on what she was thinking in developing the dish?

The operative report had little worthless verbiage. The exception was the long INDICATION FOR PROCEDURE paragraph. It contained the overblown CYA wording, certainly mandated by some hospital bureaucrat. They warned me of death, bleeding, scarring, re-fracture, pulmonary embolism, stroke and more. Yet, amazingly, that pathetic agonizing and broken man said to go ahead, to cut, drill and pound metal into bone.

The glory of the document is the description of the procedure. It has both the physical facts and the surgeons’ thinking and deeds.

tibia nailFor the mundane and physical, I found that my titanium rod (nail in surgeon lingo) was a proprietary product of Synthes Global. It was 360mm (a little over 14 inches) long,  which is mid range; they make these for tall and short sorts. The color image is from the company site and shows how it comes with pre-machined places for the screws (pins to surgeons).

(Pix trick: Click an image for a larger view.)

When I recently went to a follow-up with surgeons (not the ones who repaired my leg), one of my questions was about red-cell production. Before the operation, the lead surgeon glibly said the tibia was hollow and they would just push the nail in to hold me together. In reality, it contains cell-manufacturing marrow that they need to drill and ream out. According to the follow-up folk that means an insignificant decrease in blood making. The tibia is not a major player in the process.

The more interesting parts of the procedure description were what they did when I was insensate and how they decided to treat or not treat the shattered fibula.  For the first, the description made me think immediately of college students who paint their chums’ bodies and faces or pose them for absurd photographs when they are passed out drunk.

In my case, they did what was necessary for the tibia, including screws top and bottom to hold the rod and bone parts in place. Then:

At this time, we assessed rotation of the fracture. We assessed rotation by matching APs (anteroposterior, front and rear)  of both knees and then matching the AP of the affected limb to the AP at the contralateral limb. With this rotation, we locked in the distal screws. This was done with perfect circles. Next, we assessed the stability of the distal femur (sic and should read “tibia”) fracture. We stretched the ankle in multiple directions, none of which showed signs of instability at the ankle or medial joint space lining. As a result, we did not like to fix the distal fibular fracture.

That contains two punchlines. One is the manipulation of the unconscious guy. The other is the laissez-faire non-repair.

To the first, even though I’m that guy, it is amusing to think of my puppet-like treatment. While in the hospital, a kindly nurse had sympathized the day after the surgery when the residents, the big shot and the surgeon who led the operation visited to examine their work. She said she expected to hear me scream, that such was the norm for that first visit.

Sure enough, one of the residents roughly grabbed the leg from underneath where the tibia break was. A geyser of pain passed through me, taking my breath and flooding my eyes. Rather than scream, I yelled at him to show some thought and sensitivity. From that point, several surgeons in turn lifted the foot and ankle by holding my big toe. In retospect, that image is amusing.

Afterward, the nurse said that the orthopedic guys were famous for rough treatment. They did their work as the report states, when the patient is not aware and cannot scream or flinch. They seem to choose to ignore the difference physical awareness brings. That’s a reasonable shield considering the nature of their work.fibula shards

From the operating surgeons’ description, I envisioned my fibula end as a short stack of pebbles. They said that the muscles and tube of fascia around the bone would more or less hold it together.

In x-ray reality though, I see that the bottom of the bone is shattered and splintered. Yet, I can see what they were thinking when they had my leg cut open. The shards are close enough together that if moving in the next month or two does not displace anything, my body has a fair chance of putting enough ossifying mortar stuff there to create a bone where there’s bits and fragments.

“As a result, we did not like to fix the distal fibular fracture,” wrote the doctor. It was a judgment call and sensible enough. The alternative of a metal plate with wee pins to hold things together would be looking for trouble. There’s not much bone for purchase there and doing that would mean a later operation to remove the props.

Back to the report, being the guy in question, I am a bit squeamish reading the in-OR manipulation of my parts. It gives me an out-of-body experience to mentally see my anesthetized self being put through torture-like movements. Yet, overall this is a riveting (pardon the pun) exposition and explanation.

Would that we had more what-we-were-thinking docs about our lives.

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Close-Enough Body Repair

March 6th, 2009

Another veil of illusion fell yesterday during the first follow-up visit following my broken-leg surgery. I had honestly and truly bought into the proposition that orthopedic surgeons were flawless, perfectionist artists.

Instead, I discovered very visually that they seem to share the same fundamental belief that most adults arrive at — doctors don’t heal people; the human body in its almost magical power does…or not. (Pix note: click an image below for a larger view.)

While I had envisioned my tibia and fibular breaks to have been realigned and repaired with great precision, I was naive and ignorant. The reality of surgical craftsmanship was both coarse and close-enough. I had imagined a Super Glue®-style pottery repair, showing only a fine crack where the adhered pieces pressed together. Instead, my bones are still broken and my body is left to its devices to grow enough grout-like material to fill the gaps and in effect create a larger set of bones.

Even at what feels like a patriarchal age in this repair period, I learned something yesterday. That was both disappointing and clarifying. It does me no harm to discard the delusion that surgeons are somehow different in type from other physicians. In mind and conversation, I had held that they were craftsmen and artists, in no small part because they could see and manipulate the body parts needing attention.

Yesterday was my first look at my leg x-rays. I should have asked to see the pre-surgery ones. They must have been grim. That would have given me additional perspective when I saw the post-operation, pre-fill-in-the-gaps ones.

leb topThe short of it is that both bones remain separated. My body has some serious rebuilding to do. I understand now why they speak of it being realistically a year to get my leg back. It also humanizes the surgeons for me.

Consider the tibia (the larger of the two lower leg bones). I now have a permanent titanium rod the length of it, with two screws top and two bottom holding it in place and keeping the two major pieces together.

There is a large, visible, pointy split left with no apparent effort to bring the splinters close enough to glue.  The next time I see the jolly cutters, I’ll ask whether leaving the gap and making the body fill in the space creates more ossified material, hence a stronger tibia, than had it been pressed together. In other words, was it expedience or wise planning to leave me with an obvious break?

Then just above the ankle, the broken fibula is in pieces still. The two surgeons I saw yesterday fairly giggled in pooh-poohing my questions about that jumble of pieces.

leg bottom

Basically, their version is that the bone itself is wee, not particularly weight supporting and fairly vestigial. One said that they let broken lower fibulae repair themselves or not. The other added that if docs need a spare bone piece to repair a more functional osteal unit, they cannibalize (my word) the fibula to get one.

So, what can I learn from this? Most obviously, my master craftsmen are more like pretty skilled weekend repairmen. In my case, they seem to have done a quite serviceable job that needs only to work, not be pretty.

From the outside, once the red, purple, wrinkled and muscle-toneless leg returns to its glory with use, there will be only a few external scars. I’ll set off airport and courthouse alarms and then have to pull up my trousers for wanding, but my beautiful calf and skin will look fine again.

 

Wonderful skills of our corporal factories

Inside, it is a combination of surgical skill but more of the body’s gross and fine powers to make itself whole and functional. Apparently, the shattered bone pieces need only to have been brought close enough in a couple hours of surgery. Then the major work of correcting and the real repair is, as the expression goes, afoot.

The flippant surgeons in the hospital did the over-the-wall thing. They said I could walk on the leg the next day…if I wanted. That is literally true in a structural sense. The rod in the bone is in effect an internal splint, giving me the physical capacity to stand even while the bones remain in multiple segments.

Of course, the reality is that even for someone who doesn’t wallow in the emotional aspect of pain (a family trained trait), I needed a couple of days and physical therapy sessions to be able to 1) use a walker at all while standing with eye-flooding pain, and 2) to shuffle and thump my way down a long hall to a set of stairs, and then stumble up and down a flight of stairs on crutches.

The surgeons came clean yesterday. Unlike the in-hospital glibness of I’d have my leg full back in six months and could hit the stationary bikes at maybe four months, the follow-up estimates are twice that. I go back in six weeks to see if I am lucky and healthy enough of the body to be a quick bone-generating sort.

I end up with my intrinsic and learned faith in my body as self-repairing. I’ll be sure to get printouts of the x-rays toward the end of next month. I’m hoping for some ossification in the big gap, my body’s own grout.

So, far better than centuries ago when a break like this would get a splint to heal or not having surgeons pound a rod from the knee down the ankle is good. Yet, it’s not great and works only because of the wonderful skills of our corporal factories.

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Insomnia’s Unwelcome Gift

March 3rd, 2009

Incrementally but relentlessly, I fretted myself into ominous states last night/this morning. Insomnia was a cruel companion.

Between considerable pain, medicine-induced frequent urination, and having to prop my healing leg bones in a cushioned fortress, I have not slept long or well. Yet last night showed me what many likely know — a mind weakened by fatigue loses detachment and reason.

Since Sunday, I had been getting slowly optimistic, even cocky. I have a new mobility and for the first two-thirds of the day, even lumbering loudly upstairs with a crutch and the handrail is not all that painful. By the end of the day, I’ve been active in my limited way, going to and from the upstairs office, up and down the 13 stairs, on my little commuter road of living room to dining room to kitchen. Toot toot.

According to the brochure for trauma patients, I have move from the inflammatory stage to the healing one (page 22).

My sang-froid slowly disappeared last night. It gives me yet another what-can-I-learn-from-this moment.

With both tibia and fibula snapped near the ankle, I know too well I was not and am still not whole. I hear I won’t be on a bicycle for maybe four months, not counting those bike-like objects at the gym.

The rod making my tibia more or less one piece and the flimsy (seems not an intelligent design) fibula held together by the good graces of the surrounding muscles have their drawbacks. Sometimes considerable pain suddenly manifests. More often, muscular and neural discomfort visit and just won’t leave for the longest periods.

Last night though, the heel monster got me.

I dozed off with my leg on the stack of pillow and over a quilt to separate knees and ankles when I was on my side. Burn! Stab! The heel felt hot and like it had been entered by a big pin.

That recurred, ebbed and continued for hours. It wasn’t start up the narcotic again pain, but this monster had no intention of letting me sleep. As I tried to shift into a pain-free position to no reward, I became aware that I began to concentrate on the horrifying options. Somewhere I knew it was fatigue taking over.

My leg does have the Dr. Frankenstein assembled humanoid look, filled with staples top, middle and bottom. So, I found my sleepless and unhappy self wondering whether there were infected staples on the back of the heel that I had not noticed.

The sudden infection or, who knew, blood poisoning came into play in my susceptible mind. The pain, the paranoia, the muddled perception all feed into the insomnia.

Come the morning, as my wife went to work, I somehow passed out for a solid hour and woke up less crazed. With only that extra mental healing, I could open the Aircast, check for sores, rework the dressing and super sock, and add some reason to my hope I was not in big trouble.

I realize that I am not often in such a state. Yet what a powerful small play it was in which I acted.

What can I learn from this? Probably not much for myself. The power of insomnia-induced fears would likely still overpower me in a similar situation. I can hope that this experience will mitigate that, but I can’t be sure.

Perhaps though for others — my wife or one of our sons or friends — I can respect the monster and do what I can to resolve those fears before the feed back into themselves. This is a surprising and nefarious netherworld of the mind.

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My Diminished Self

March 2nd, 2009

I find that I am more comfortable doing for others than I am being done for. That seems to fit with my preference to praise others rather than be praised.

With my shattered leg healing in its own ossifying time, I have had little choice on being cared for and catered to. My wife in particular has done my work, what used to be my work. She has been cooking and shopping, she shoveled a foot of snow, including digging out our vehicles today, and she cleaned and prepared for that church dinner with 16 guests almost solo.

In what must be largely efforts to make myself feel better and more useful, I have done a few things my feebleness allowed. I staggered and leaned into the fridge to empty and reseat the meat drawer she could not figure out how to reinstall. I cleaned the upstairs bath, at least from the sink level and above for that dinner. Otherwise, I feel like a barnacle on the ship of family.

Our youngest is still living home. He, if not cheerfully, at least willingly has helped as I ask. I can’t carry a cup or plate with my crutches. I try to stuff self-assembled lunches into a bag I can carry, but he does for me.

My wife though does the care-taking.  She brings me meals when I am too sore or pained to thump down 13 stairs. She moves the crutches or walker from floor to floor as helps me.

toiletPerhaps worst from my perspective, she has emptied and returned the urinal  bottle I used when I simply could not navigate to the bathroom during the night. While we were both active parents to all three of ours, changing and cleaning up from all manner of egesta top and bottom, being in a prolonged state where someone has to carry away my urine because I am unable to do this most basic of functions the way American Standard intended is humiliating.

Granted I should not be so self-absorbed. Many are more disabled by birth, disease or injury. Probably if my infirmities continue or worsen instead the likely healing in the next two months, I would become more accepting and less emotional.

Yet, as the standard-issue liberal sort, I have to wonder now what these thoughts and feelings reveal. Might I come out of this a bit improved, as well?

I grew up in a family of volunteers and do-gooders. I have done that first by being swept along in the helpfulness and duty of my mother from elementary school and then formal volunteering from early teens. I’ve varied the intensity but never stopped.

Now I am again on the being-helped end. Once before, 16 years ago, we were in need. At eight months pregnant, my ever avant wife broke her ankle just walking down the steps of the back deck. I had recently been moderately crippled when a big disk (L5/S1) went into my spine. We were a mess, but we had some meal deliveries from church and my in-laws arrived to nurse us (really her).

I could urinate well enough on my own, thank you very much, but I was reduced to shuffling around. I bulled through cooking for everyone, but each meal was a mini-death march. Yet in my self-interest, standing to cook was far less painful than sitting or lying.

That period should have pointed me to my odd concept of preferring to do for others. It did not. I was busy trying to be as fully functional as possible, while taking care of my more-broken wife.

So, now I have something specific to meditate on. What is my relationship with helping — helping others or being helped?

Again, this brings up a chuckling point. Probably my most repeated question to my sons as they grew and met disappointment or distress was, “What can we learn from this?”.

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Churching at Home

March 1st, 2009

Quiet and discomforted in my bed last evening, I fully recalled those loud adult functions of my youth. Adults downstairs laughed and shouted at volumes that would have gotten us kids punished, while we were upstairs in the covers with our books and reading lamps.

church in a cottage

Church came to me and I was unable to meet it full on. I had overextended myself with the walker and crutches…plus, there were so many of them (16) and they were so loud.

In the new UU-style canvass dinner system some use, the pledging units do an elaborate potluck at a private house, get a tiny bit juiced, talk about what that church means to them, and leave with their pledge cards. Bonhomie brings beneficence (without the hard sell), the theory goes

I did put in a cameo, waiting until everyone arrived and successfully thumping down the 13 stairs on a crutch and the rail, knowing the crowd drowned the thuds. I chatted for awhile and didn’t have to detail the nastiness of the breaks or surgery — subjects that bore and irritate me from the repetition. I couldn’t join in the wine, because of medication, and would fallen behind the happier swillers as well.

The grouping included only a couple of men and was largely lesbian couples. I had known several of those sets from a previous UU church we shared in downtown Boston. No one was a stranger to me and in a little better health, I would have enjoyed the banter.

Several of my lesbian friends have remarked to me how loud they often are, particularly as a couple. In friendly environments as our house with peers, religious and political, around, they fairly burst with exclamation.

 

 Bonhomie brings beneficence

Taking my leave and upstairs in either my office or my bed, I could muse on nearly four hours of the happy noises. I have a vague recollection of a BBC Mystery series written by a woman who remarked on the high-pitched din in a women’s school dining hall. She compared them to strident birds (starlings or grackles as I recall) and wondered why women sounded so loud and unpleasant.

Here it was not nasty though. I am sure had it been many men, straight or gay, the sounds would have been deeper and more muted, but they likely would have also included competitive posturing. I’ll take the women talking all over each other in affirming cacophony.

I was so beaten up by pushing myself around the two floors that I did manage a half-hour nap. The bedroom door was open, yet I dozed. I looked at the black-on-lime clock display on waking and wondered how my brain could accommodate the noise. We humans may not be all that evolved, but in many ways we live our little miracles.

Surely if church was as enlivened as cottage dinners, this congregation would double. Such a prolonged happy exchange speaks well of the fellowship of those you know, but not all that well, yet are jolly enough with. Church coming to the house is not bad at all.