T.G.I. Monday

I only had one case Friday. A ditzel at that, calcaneal fx. Not that it wasn't challenging, just not very fulfilling for myself and, it is all about me. Didn't have any call Friday night or Saturday night. Didn't work at all this weekend. Well, not yet anyway. I am on call tonight for the trauma surgeon, the ER call surgeon and the ortho trauma surgeon. Despite the numbers, chances that I'll work get slimmer as the hour grows later. The weather also plays a factor. The colder it is, on a Sunday night especially, the less chance Sum Dood will be out in the streets creating juicy traumas.
Tomorrow however is shaping up nicely. Two total joints in the morning, one hip and one knee. I am excited because I believe we are using the Zimmer NexGen on the knee. Probably posterior stabilized but I'm not sure. It is the system I know the best though some will say it is not the best system. Then I rush across town for a sigmoid resection with one of my favorite surgeons. I have so many favorite surgeons. I am very fortunate. I am psyched to go to work every day. This week, I have even been chosen as assist over another surgeon on two occasions by two different docs. How totally awesome is that?

Don't shoot me, but....

After all of the pain, after all of the whining, all of the sleepless nights, torturous days and fearful thoughts, I feel so much better that I have decided to cancel my Thursday appt. with the Physical Medicine and Rehab Doctor. Bad Patient. I don't make this choice lightly, and I am not saying I will not seek treatment eventually, but I can do so on my own terms now that I am comfortable enough to work and sleep with minimal discomfort and seem to be improving daily. I even talked to three different surgeons and the concensus is , if they were me, and they felt better, they would cancel too.
I will probably follow a different course of treatment though. I think I'll go to the chiropracter. Just kidding! I will probably go and establish myself as a (bad) patient with my new Primary Care Physician (won't she be thrilled!), and go from there.

On another note. Worked two nights of call in a row. I haven't seen any call action in a long time and I've missed it. Even had a good talk with one of the ortho trauma docs. I have been telling him for the last year that he can feel free to call me when he needs help. I finally quit offering because he has never called. Last night I just happened to be at the hospital when he booked his two tibial nailings. I was actually hanging out for the general trauma surgeon. I made him ask me to help. I didn't offer. We had our chat, which he instigated, and he say's, for about the umpteenth time, that he will start calliing me. Maybe he really will now, because this time, he thinks it was his idea. You know how men are. Right now it's off to the shower before I'm called in again. After two nights of orthopaedics I'm ready for some general surgery.

Happy New Year!

You want some cheese with that?

So much whining! My apologies to my four or five faithful readers and to anyone else that has stopped by, for the posts of whine. I shall now resume my regularly scheduled blog presented with limited whine-like interruptions.

Seriously?

The same anesthesiologist/pain doc that had given me the Lryica samples and was all set to give me an occipital nerve block in (my old) the OR, has just informed me, through his scheduler, that he feels I shouldn't come in to the pain clinic today and finally get that block I've been begging for. He thinks it's best that I just wait until my January third appt. with the PM and R doctor for two reasons. I never got past the first reason, "Your insurance may require pre-approval." I calmly explained to the lady that I am willing to pay for this out of pocket because even if it were pre-approved, I still have to pay it out of my $3000.00 deductible. "Well, we wouldn't want to risk losing your benefits." Didn't really matter what the second reason is anyway, he obviously has reservations about doing it. I should have taken it when he offered it the first time. What's seven more days of agony? Assuming PM and R docs even give nerve blocks?

Update: Countdown to the New Year

Tuesday I was ready to sit down and blog about how great I was finally starting to feel. I had been at my desk catching up on claims and phone calls, not wearing the soft collar and enjoying a greater range of motion than I had since Tues last week. Somewhere around dark thirty the ibuprofen wore off. Back to the original pain level, no blogging today. Take 800 more mgs of kidney killers, turn on the heating pad and doze in the chair.

Wednesday morning I took my meds 1 hour before my first case, and felt well enough to assist with out wearing the collar. My next case wasn't scheduled until three hours later. The stiffness in my neck is just about gone. My range of motion is improving. The last thing that has been torturing me for the last 8 days and nights is the neuralgia on the right side of my neck from the occipital nerves. Each shooting, biting jolt of electric pain causes my neck to contract, my shoulders to scrunch up and my right eye to close as I hold my mouth in a twisted grimace. The neuralgia breaks through the ibuprofen after only 3-4 hours leaving me with 4-5 hours of suffering before I can re-dose. The Flexeril seems to have little or no effect on anything but my alertness. Neuralgia trumps Flexeril. I'm dropping Flexeril from my regime.

In final desperation I talked to one of the Anesthesiologists who also does pain clinic. I asked him how to go about setting up an appointment for an occipital nerve block at the clinic. He was going to give me the block right then and there in the OR, but we were at the hospital where I used to work and I was uncomfortable with that. If word got out (I'm sure there is at least one person there gunning for me) I might risk losing my privileges. He made some phone calls and learned that the doc who was on that day had already left the clinic but he could get me some samples to try for now. That was awesome, I told him, and while I was there I would go ahead and set up an appointment.

Got to the office and after some confusion, one of the women came out with a sample bottle of Lyrica. Sounds so cheerful doesn't it? Lyrica, like lyrical. I asked her how to go about setting up an appointment for pain clinic. She informed me that the clinic was closed from today until after Christmas! That's six more days of agony! I left feeling less than hopeful that this new med was going to solve anything, and headed out for my next case.

It was now 1400. My neck is screaming from the incessant, squeezing neuralgia. I put on my thyroid shield, the cervical collar my lead apron and scrub in. Fortunately this is a distal radius fx so we get to sit. The collar gives me somewhere to rest my head when my neck is tired of fighting. The crew makes fun of me of course. I tell them I thought I could pick up some sympathy dates. One of them suggest I decorate it for the holidays. I tell them it's getting embarrassing because of the food stains on it.

After the case, I was sitting in the doctor's lounge listening to my voice mail on speaker phone with my collar on and my head resting on a pillow on the back of the couch, holding the phone up at eye level when the surgeon I'd been working with stuck his head in the door. He told me that the ankle fx we are doing tomorrow is a simple one and if I was in pain, he could get by without me. I thanked him and told him it would depend on what this new drug does. I sat there for a minute contemplating my next move. I had full intentions of going to Trauma Grand Rounds tonight at 6 pm. It is only 3:30 and I'm in agony and I can't redose until 5 pm. I decide to go home and try the new drug.

I get home, feed the horses, get in the house and prepare my recliner for the evening. Heating pad, neck roll, warm fuzzy blanket, large tumbler of water, and bottles of pills. I had made the decision to sleep in the chair because while lying down on a pillow wasn't too uncomfortable, trying to turn over or get out of bed was. My chair will recline to almost horizontal, with a little pull on the armrests and a shift of weight and I am able to get up without straining my neck. I have had no appetite since this started which is good, cause I barely have any food in the house anyway. I get into my heavy sweats and settle into the chair. I pop a Lyrica and even though it is 1/2 an hour early for my ibuprofen, I pop four of them also. I hate loading up on ibuprofen and I try to keep my kidneys flushed.

There is a blessed two hours of almost total relief after dosing, and this is the only time I think I really sleep. The rest of the evening I float in and out of semi consciousness. Somewhere in time I awake and manage to stay alert long enough to watch Criminal Minds. I decide I better eat something so I make some toast. I let the dog out and drift off again. I wake up and the news is on. I can't remember if my dog is in or out so I get up to look and there he is waiting. I let him in, share the crust I saved for him and doze off again. Each time I wake, my heating pad with the built in safety switch, is off. I crank it back up, wrap my neck and whole head in it and doze off again. The next time I open my eyes David Letterman is on. I realize that I have a 730 start tomorrow and I have no alarm set. I reach for my cell phone and the TV remote. With some difficulty I set the sleep timer and the awake timer on the TV. I drift off. The pulsating neuralgia pain keeps me company all night, never letting me drift away completely, keeping me painfully aware of it's presence. The cat has been keeping my lap warm, the dog sleeping in the living room with me instead of on his own comfortable bed in the bedroom. I awake again and see that the TV is off. Good, the alarm should work. I can't remember what I did with the cell phone. I feel the neuralgia trying to grow stronger. I fantasize that the new drug may have reduced the severity but I am fooling my self. I open my eyes and I am aware that the light is changing beyond the curtains. I drift off again. I try to remember if I set the cell phone alarm. Drifting off again. Did I? That's okay,TV set to wake me up. In my haze I converse with myself trying to remember what time the sky gets light and wondering if I really did set any alarms when I jolt awake. I turn the TV on and check the display, 6:30! So much for the TV awake timer. I turn to look outside and it's snowing. I eject myself out of the chair and my neck punishes me instantly with a prolonged pulse of electric pain. The right occipital region of my neck spasms making it painful to hold my head up. I go to the bathroom and wash my face, brush my teeth, no time for make-up. My hair is is still in yesterday's braid and so it will stay. I throw on some clothes. I start to take a Lyrica but the precautions warn of possible dizziness and difficulty driving. Since I took the first one right before I started dozing, I'm not really sure how it did affect me. I decide with the snow, I'd better wait. I search for my cell phone and find it wedged between the chair cushions. I try to round up the dog to put him in the office with the doggie door. As I gather his meds, I look at the clock, it is almost 7 am. With snow, my commute will probably be a minimum of 45 minutes. If I was in my truck right now, I'd still be late and I'm at least 10-15 minutes away from leaving the driveway.

Admitting defeat, I call the surgery center and ask them to tell the Dr. that I am going to take him up on his offer and I won't be in this morning. I make some coffee, eat a blueberry fiber muffin and pop a Lyrica and 600 mg of ibuprofen. I'm going to keep the ibuprofen to 600 mg every six hours. Fourty five minutes later I feel great again. In fact I motor around and clean house a bit. The Lyrica does make me dizzy but not dangerously so. Although I was told to take it every eight hours, I think I will wait every 12 hrs. It's main target is fibromyalgia and the insert reads that most people feel some relief after one week. I think I cried when I read that. Here I was, practically crawling and begging for instant relief before I turn suicidal from pain, and bless him for giving me free samples but, after ONE WEEK!

I just want pain relief from the neuralgia until after January one. Then I am off to the neurosurgeon or a PM and R doctor. I'll sign up for my MRI, CT, XR anything you please. Just get me to the new year.

Ramona and Bongi, thank you both for your concern and checking in on me.

Bongi, I know this is nothing to fool around with. Since the irritation is with the occipital nerves and they arise from c-2, that is a dangerous level. What is that saying? C 4-5 stay alive? Something like that. Perhaps I had some intuitive foresight as to why I haven't been overly anxious to break my horses myself, and I know I shouldn't run anymore and have turned to hiking instead.

I have always had some sort of neck pain. This was chronic for about two months. While I'm sure the slipping on ice could have been a trigger, it was going to catch up to me eventually. You both know the position of your head while you operate. You both know which muscles ache after many hours in the OR. I'll get a fusion if it keeps me assisting, but I'll start with conservative treatment.

Oh, oh...

My c-spine film circa 1985
Well, I woke up Sunday morning With no way to hold my head that didn't hurt.
-Johnny Cash
I had undiagnosed, untreated whiplash somewhere back in the early eighties. They had me move my head through a range of motion, said, "Yup, you have a still neck." Gave me some valium and sent me on my way. The next morning I remember that I couldn't lift my head to get out of bed. About five years later, the chronic headaches started. Everyday, without fail. When I finally sought treatment films revealed a reverse curve in my c-spine. All these many years later I still have a fairly straight c-spine with just a hint of normal curve.

For about the last 5 weeks, I have had localized muscle aches and spasms along the right side of my neck annoying enough to interrupt my sleep several times each night. Monday morning I went out to feed and slipped on the icy packed snow, I didn't fall, but did a sort of chicken strut with my neck. By Tuesday morning, my entire neck was fairly stiff and sore. The case I posted about on Tuesday started at 1500 and we finished around 2200. Still I was no worse for wear. Wednesday had morphed into a full day, starting at 1100 with a laparoscopic right colectomy and ending at 1930 with an ORIF of a left ankle. The entire day my neck was killing me. Range of motion was now greatly decreased and pain and stiffness greatly increased. A "helpful" rad tech running the C-arm, poorly I might add, decided to adjust the OR light to help us see better. Unfortunately he is about 4 ft tall ( I am 6' o) and drug the light down to his level so as I stepped away from the field to switch places with the surgeon, of course I rammed the light with my head sending the jolt right down my already tortured c-spine. Lucky for him I was scrubbed in because my impulse was to pick him up by his neck and toss him across the room. I grabbed the light and sent it up to my arms length and focused it on the field from there. I made a very theatrical production out of it so that maybe he would notice? No, about ten minutes later the little bastard did it again! This time, at least I was aware of it. I ended the night with a raging neck ache and now unable to determine if the pain was muscular in nature or skeletal.

Thursday I had only one case at 0900 and we were done by 1030. My neck still screaming in agony. I had some errands to run before I could go home. I purchased a soft cervical collar. It hurts to hold my head up. One naproxen sodium the day before didn't touch the pain. One Daypro (okay they are about two years expired) the next day gave me about 1 hour of barely noticeable relief. When I got home I alternated ice and heat, ice bringing much greater relief than heat. I took two, 200mg, ibuprofen when I went to bed. I managed to sleep until 430 am when my neck would not quit screaming. I took two more ibuprofen and fell back asleep until 0930. Thank goodness I don't have any cases today.

The pain is a little more localized but no less intense this morning. It starts at the occipital on the right and travels all the way to the right shoulder at about the level of C-7, T-1. With a frightening trigger point at about c-3-4, or 4-5. My range of motion is limited to flexion and extension with discomfort. Lateral flexion is extremely limited more so to the left, and rotation to the left or right is barely a few degrees.

The good news is that my (self) diagnosis is most likely cervical strain. The differential DX is cervical spondylosis or herniated cervical disk. Regardless, both may be treated conservatively. I doubt either of the latter because I have no neurlogic symptoms in my arms, though I'm not sure how to give myself a neurologic exam ( the more I dwell on it the more I imagine weakness in both arms). I may have reached a therapeutic dose of ibuprofen as the two I just took seem to be working fairly well.

The bad news is that acute pain may take up to one week to subside I have a full week next week. I need to get hay today. Our Christmas party is tomorrow night. I have a three thousand dollar deductible I just as soon not use until 08. I have a dying dog who needs daily meds and two hungry horses so I can't do hospital time. I have no established PCP. I am a self confessed BAD patient.

I find it very frustrating and annoying to be in this position. I can't work on muscle relaxants, can I? Are there any varieties that would not impair my function? If I can just complete next weeks surgical obligations, the following week is the week of Christmas and so far nothing is scheduled, I only have a shitload of call. Perhaps I can heal. Or better yet make to 2008 when I can commit to some down time and that 3k deductible.

It's not always about the money.....

Yesterday at the scrub sink I am scrubbing with one of the trauma surgeons who also uses me for scheduled general cases. We are getting ready to do a mastectomy. I mention that this is a slow week. I only have this one case today , one on Wednesday, and one on Thursday. He tells me he has a case tomorrow but I'm not on it. I ask him what it is. It's a trauma patient from last year who had been shot from posterior to anterior and the bullet transected the vena cava, took out the hilum of the right kidney, (may have nicked the liver, I stopped listening when I heard transected the vena cava) went through the duodenum and out through the abdomen. He now presents with various fistulas, yada, yada, yada.....I quit listening again as I daydream about what a rush it would have been to be there for the original surgery.
"Do you have help?" I ask.
"No, (my partner) was going to help me, but he decided to take some time off this week."
"I don't have anything scheduled, I'll help you!"
"You don't want to scrub it." He says. " This is a Medicaid patient."
"I don't care, I always want to operate." I assure him.
"You don't get paid by Medicaid. Besides, it may keep you from something that would pay you."
"Well, if something paying comes up then we'll have a change of plans. Otherwise, plan on me being there."
What is he, nuts? Did he really think I would want to miss this case?
He knows I'm a junkie. Just last weekend he acknowledged that I was a trauma slut. Of course I immediately corrected him and told him I am a trauma whore. In retrospect I think teasing me with this case was a test to see just how far I am willing to go for free. Hey, wait a minute, I guess that does make me a slut.

The Things You Learn in the OR

Here's how naive I've become. A gay man of average weight made the comment..."Thank god I found me a chubby chaser." I thought this was a new name for gay men. I have since been set straight (snicker) and was informed that a chubby chaser was someone, particularly a man, who chases chubby women.
I visualized the wrong chubby. I thought it meant chasing after The Little Chubby.

Love, Trauma Style

One of our beloved trauma surgeons just happened to turn 60 yrs old the same day he was on trauma call. As expected the trauma pager went off for a trauma blue sending him to the ER. When he arrived he found the ER team already surrounding the patient, but he thought it a bit odd that there were no monitors or IV, no law enforcement officers, no paramedics or flight crew giving report, very odd. As he made his way to the head of the patient to begin his assesment he understood why. Gazing serenely back up at him with an inviting smile was none other than......a blow-up doll.

He carried the joke on by delivering his critical patient to the ICU. They were poised and ready to assume ventilations when little miss dolly arrived.

I don't know if he has given her a name yet, but I bet she has a home in the trauma on-call room.

Slowing Pains

My on call dry spell continues. Another week gone by and nothing. This week I had three days with no scheduled cases and call of one persuasion or the other Monday thru Friday. I've figured out part of the problem. It's hard to find work when your hospital is one divert status or another. The town I live in had a rapid growth spurt which, in my opinion, has destroyed the clean air, open spaces, water supply, traffic flow, cost of living and overall quality of life in my home town - but that is a whole other rant. There are four major hospitals here, a 538 bed level II trauma center which is in the completion stage of expansion, another similar sized (380 bed) hospital, and two smaller hospitals with a combined total of 165 beds, all with "full service" (the latest advertising phrase) ER's. (photo credit)

Here is my impression of how the game goes...keep in mind, I am talking about patients arriving by ambulance only. Patients arriving by private vehicle or on foot can still come in and join the party. The trauma center ER usually fills up first. People without insurance that don't express a preference seem to end up there. Once all the ER rooms and hallways are full, the ER informs ambulance dispatch that they are on ER capacity divert. This generally shifts the flow to the next largest hospital until they too end up on ER capacity divert. It doesn't take long for the two smaller hospitals to join in on the fun and now all four are on divert. So where does the ambulance deliver at this point? Well, this is where the game gets fun! Since all four hospitals are on divert, they all have to be considered open again. I think there is some sort of time frame that they have to honor, say 2-4 hours (?) before they can reclaim ER capacity divert. This seems to be the most common divert status, however there are more options.

Critical Care Divert means that all of the ICU beds are full. I believe this includes all ICU's, trauma, general, pediatric, cardiac, the one exception may be neonatal. Sometimes surgeons on general ER call love to hear this. When I am on call, I hate to hear this! Even though the trauma center may be on critical care divert, a patient meeting trauma criteria and an appropriate trauma score still comes to the trauma center. So where would this patient go after surgery if there is no ICU bed? If you can't go to the ICU, sometimes the ICU comes to you. Qualified recovery room nurses and an ICU nurse (more than likely one who has been called in) will manage an ICU patient in the recovery room overnight or until an ICU bed becomes available. Nobody likes to play this game.

And the final divert status I have not quite figured out yet. It is the coveted Closed Divert. I imagine that it is just as it sounds. Closed. Period. No ICU beds, no ER rooms, no floor beds, no room at the Inn. Fortunately this status doesn't happen too often and I have never heard of all hospitals being closed. I believe that when the trauma center is on closed divert, and it always seems to be the trauma center, patients are shipped to the next regional trauma center. When the OR staff walks by and see's CLOSED DIVERT written on the grease board, you can almost hear an audible sigh of relief. It means the case load you see, is the case load you get. No add on's unless the hospital re-opens or it's an emergent inpatient. When I hear closed divert I also utter a sigh but it holds a different meaning.

The rapid growth has obviously exceeded the hospital capacities. I can't wait for the trauma center expansion to be up and running so I can get back to work.