Friday, July 30, 2010

The US healthcare insurance scam strikes

First off, let me get my perspective on the healthcare system in the US out of the way: it is abysmal. It is a pity that so many in this country are misinformed, and think that a for profit system can ever benefit the patient. It is an impossibility, a paradox. In its very essence that company which does what is best for the patient will go out of business as their customers will be healthy and not need service. It really is that simple. So I am completely not surprised the following happens...

I have full insurance for this, probably some of the best plans left in the country since it is one of the few remaining benefits of a quickly declining union. However, there has yet been a single visit, claim, or procedure that did not produce a mountain of paperwork, or require lengthy menu navigations to get to a human being who fails to fix the problem the 5th time you speak with them (or so it seems that way). Horizon BC/BS- F YOU. And that is my professional opinion.

Apparently because the hospital did not submit some progress notes in a timely manner they are denying the claim, and they will have to submit again. Being an RN I know people who work in the insurance side, and there is one thing I know for certain--this like many other letters that get sent, are done so on purpose and without real merit. ALL initial claims are ALWAYS denied. Studies show that is the first line of defense against payment and guarantees more profit. While there maybe one or two companies out there that do not practice this, this has been my experience. While they will eventually pay since everything was cleared, my bet is it will take the better part of a year for things to be settled. I mean really, do you need a progress note to justify a 3 day hospital stay for a patient who had two surgeries on the same day of this magnitude...there is 0 justification here, just profit motives.

Wednesday, July 28, 2010

Sciatic Nerve--what the heck is it?

I'm going to spare much of the scientific jargon here and make this one simple. The sciatic nerve (hence sciatica-associated pain) is formed from smaller nerves running from the lumbar to the sacral nerves, and is composed in the leg and then further branches off into smaller sections. It is responsible for a lot of the pain in those with bad disks, spondy, or other similar conditions. Irritation is typically pain, sometimes numbness/pins needles, however if major or in cases of sudden onset sensory deprivation or extremity paralysis it indicates acute damage and should be treated emergently.

Different location of pain differentiates spinal level
However the nerve itself does not just jump out of the spine. It is actually several nerves emerging from the lumbar vertebrae and sacral openings that merge into a big bundle that becomes the sciatic nerve. What is important here is that the location of the pain is critical to determining the level that is injured in the spine. Here is one diagram to the right that shows an approximation of which nerve is responsible for which pain. The one on the right is very broad, whereas the one below is much more specific.

This diagram demonstrates a "map" of the nerve origination vs the location of pain felt.

Why am I spending so much time on this? Because the pattern of pain I have been experiencing is the s2/s3 variety. That means it is just inflammatory pain from the surgery, perhaps the radical reduction, or just too much walking. The MD's office agrees, slow it the heck down. 4 miles is too long to walk less than a week post-op (ok ok I was excited to be able to walk again...)

So today it has been better. Today is also my first full day off all narcs--and that will get its own post, but let me tell you it is not pleasant. However I've seen far too many patients go down the path of not stopping soon enough, and I'd rather stop a little too soon and play it safe. So what, what's a little pain now compared to the last year. Actually with the fixation there is very little back pain, and I forget I even had abdominal surgery unless I sneeze or cough. Not bad for less than two weeks out. Now the legs--that will remain for the next post.

Tuesday, July 27, 2010

No road is without bumps

As expected not everything is perfect. This weekend as I was tapering the meds down the left leg has been protesting with new found vigor. It started as a gentle calf pain after a day of some serious walking. Initially thinking a sore muscle I dismissed it, then when the next day came I worried it was a DVT. However as any floor nurse will tell you, if it is aggravated by walking and relieved by rest, then likely DVT. However that is not the case. It is actually relieved (not entirely) by walking, and is worst when I wake up. As the next two days proceeded it went through the whole leg and left hip, not just the calf, so it is definitely nerve pain (sciatic).

This is very disappointing since that is the one thing the surgery was supposed to be damn good at relieving. I am assuming it is inflammation, and likely stemming from too much walking, or the new anatomy from the reduction pulling at the nerve. My hamstrings are tighter than I ever imagined; I only have about 20 degrees of upward motion. I can only assume the nerve is as well so that is likely the cause. Nonetheless the office is getting a call so I can figure out what to do--or not do. The appointment isn't until a week away, so that's a lot of time to damage it. I'm not terribly concerned though. Since there is no sensory deficit there is likely no damage, just irritation. And it is relieved by the current pain management regimen so I can live with it for now.

Friday, July 23, 2010

It has been a week!

I've exceeded I think just about everyone's expectations in my level of functioning. The visiting nurse and physical therapist stopped in and while we had a great chat it was the last time I will be seeing them since  I am walking between 2-3 miles every day now! While the pain is controlled by the percocet I am able to do the walking with minimal pain for the most part. The trick is to time the walks with the pain meds, or really to time the most painful part of your day with the pain meds. Lots of hills here mean finding flat roads to walk on gets repetitive, however the mall is a 1/2 mile away, so at least its air conditioned, and I fit in with all the geriatrics with my cane on their early morning/bad weather walks.

All the people who are helping me are indispensible--whether getting your socks on, or picking up something you dropped, or going out and getting you something that makes you feel better when no amount of meds does--it makes all the difference. My poor wife has been stuck with all the chores and house maintenance for a while, I think I might be stuck doing this stuff for a few years after this!

I've been doubling up on calcium, vitamin D, taking MVIs, lots of meat, fish, and some veggies to give my body whatever it needs. Since dropping the 40lbs in the last 3 months I have lots of room and this way by body is in a "building" mode rather than a losing mode. Pain meds are slowing down, but waking up and going to bed are the hardest. The initial wake up I am sore like I've just run a marathon while having the flu--and before bed much the same. From the surgical reduction of the spondylolisthesis the bones, muscles, tendons that have atrophied in the past are now being used in all sorts of different ways, and I can tell you they protest. Then there is the pain from the rods underneath the skin. I am definitely becoming more used to them, but the back brace or any firm back chair/bed still aggravates one in particular.

The abdominal incision is healing well and the tenderness is much less, however there is still pain at the end of urination, quite odd. I assume it is from the bladder being stretched as everything was moved around. The 4% chance of retrograde ejaculation (potential sterilizing ALIF complication from movement), while a big motivator for a surgeon to go PLIF only, in my case worked in my favor and luckily no damage was done. Abdominal strength is back with little pain, the trauma surgeon who assisted with the anterior portion was definitely quite skilled and a few days I feel very little from the abdominal part at all. Also, always a concern with abdominal surgery, all bowel function is returned with no issues thanks to early mobilization and good diet--but I'll spare the details here.

Out of so many blogs that I read, so many accounts of this type of surgery, I feel truly blessed with how well it has gone for me so far. The pain has been manageable, I am able to ambulate (with the back brace), spend the majority of my day in less pain than prior to surgery (though with meds now), and get a 2-3 month break from work! Though I'm really hoping it fuses early and I will be able to return early (what can I say, I'm committed.)

The horror stories online made me think I was in for 3-12 months of hell, and while it still "pending" as to how it will turn out, the idea of finally being able to live proper without handicap, is something that even if it was, would still be worth it.

As they say I suppose its a matter of outlook as well, but unfortunately no pain meds or surgery can ever fix that.

Wednesday, July 21, 2010

This blog is worthless without pics!

 here you go!

This is the intra-op xray showing the donor graft being placed in the level. Notice the near complete reduction of the spondy!!!

Compare it to the prior: 

I could not believe it, but when I looked in the mirror my back is straighter than it has ever been! Of course there is a likelihood that I will lose some of that reduction as everything settles and heals (maybe 10-20% at worst from what I read,) however compared to the prior x-ray, you can see the vast difference in alignment.

Having done this all the muscles, tendons, and bones have to get used to the new alignment, but even now I am able to walk without a cane mostly (though I still do since falling at this point would be VERY bad).

Tuesday, July 20, 2010

Back home at last

Having worked with many post-op patients, I know very well how different the experience is for everyone. After surgery the majority of people start to wake up, and usually after some time the anesthesia wears off and everything else does as well, and they start to require pain/sedation meds only after clearing out the those anesthetics. Anesthesia staff remain around to make sure they are always available to prescribe what is needed to keep the patient at a tolerable level as they come to.

So before I go on, let me put what happened into context: Up until this surgery my experience with narcotics was very limited. When I had my shoulder surgery 10 years ago, they gave me some ultram for two weeks. It hurt like hell but nonetheless within three weeks I had done a good deal of PT, and made it by with nothing but the ultram. After doing the damage with my last motorcycle wreck I was given a few days worth of percocet, since I did some pretty obvious damage. The other experience was more than 11 years ago, when having had my wisdom teeth pulled they gave me a small handful of vicodins. As for the back, I purposely set out to not take anything as long as possible since that's a downhill path unless another intervention was in the future. When the PT failed, and then injections failed for the spondy, only then did I take the ultram so that I can continue to work and function for the few months prior to surgery. For those who don't know, ultram (tramadol) it is such a weak narcotic (stripped of all its "feel good" properties) that most don't consider it one. So my tolerance to pain meds really ought to be next to none going into this. And as for my tolerance for pain, hell, I've been walking around (snowboarding, hiking, playing hockey...) with a broken back and a destroyed disk for two years I think I can handle it pretty good....

When they pulled the tube I started to come to, and while initially it looked like I was going to be ok, after just a couple of minutes it became obvious I was in agonizing pain. Shot after shot nothing would make it better. I have no words to describe it, other than it was without a doubt worse than any pain I can imagine. As anesthesia ramped up the dosages the agony continued. By the time it was remotely under control, the dosages I was was at terrified me because those are levels a typical person would have stopped breathing a long time ago on. They even started with Ketamine but by then the heavy doses of dilaudid were starting to have an effect and I made it without needing the drip. Wow, talk about a rude awakening. My initial though was to wonder what the hell anesthesia was thinking, but the reality is that every patient is different, and sometimes you do get a freak like me who just doesn't respond well to narcotics. Its not their fault, they tried as fast as possible to give me all they got. If I was in their shoes I would be just as concerned giving that much to an extubated patient.

So that was the day 1 nightmare. Oddly enough all these drugs did not knock me out until later on in the evening, and then I would wake up, push the PCA button a bunch of times, nap, wake up in terrible pain, push button repeat...this went on for the next 24 hours or so. I was able to get out of bed and move around a bit that first day at least, so the optimism started to come back. Oddly enough being upright was the least painful part of that day. However having two incisions made it twice as difficult, since not only must my back be straight but using the abdominals was pretty much a no-no since they were cut as well. Luckily I had help.

The second day presented another challenge. While the pain was now mostly controlled on the PCA (where you push the button,) to get discharged I would have to go 24 hours or so on oral pain medications. The choices were either dilaudid or percocet. I decided to try the percocet since it should be an easier one to kick when all is said and done. I hit the dilaudid PCA button a couple of more times and took 20 mg oxycodone (this is about  4 percocets worth less the tylenol). It lasted a couple of hours, and then I had to wait...and wait...the next dose was scheduled for 4 hours later. Unfortunately the meds lasted 2 1/2 at best. After an hour and half of being back in terrible pain they gave me an additional 10mg. I can understand their fear in giving so much since having to reintubate or give narcan is quite a step back, however I was decompensating to pain levels that were not conducive with recovery since I essentially could not move. Eventually they bumped me to 30mg oxycodone q4 with tylenol and some valium to relax the tense muscles.

The pain managment NP then made another suggestions--I could try oxycontin since that's even stronger. However having worked in rehab for the time that I did, that is one I would rather pass on. While I know the arguments for it, and I have no doubt synthetic heroin would do wonders for my pain, I decided to pass on that one. The decision was then made to just continue the 30 mg of oxycodone with 650 tylenol added in, every 4 until it settled a bit. That way the acetominiophen dose remained consistent while I could taper off the oxy as tolerated. That worked fairly well. Now that I am home I am getting by with 15mg every 6 hours now along with some tylenol, and still able to take my walks and move around and not get too groggy. So improvement seems to be going quickly. I actually managed a 45 minute walk today just this AM, I plan to continue and hopefully exceed recovery expectations.

So the question on my mind as it must be on others' as well: Is it worth it? We shall see. Having looked at the x-ray the spondy is reduced almost completely - wow. Doing the combined ALIF/PLIF allowed the large reduction with minimal manipulation, and the pars is still intact and no decompression was needed. All statistics point to what should be a back to 100% recovery. The nerve issues are definitely gone. My left leg is not tingling, my hip is not aching severely, and the incisional pain is starting to dissipate. Once I get used to the rods that should make it even better. Right now seeing everything I am VERY optimistic, and hopefully all will go well and in 6 months I can answer this question with a resounding YES!

Saturday, July 17, 2010

And so ends day 2

I remember when having a back spasm that taking 2 percocet was enough to stop debilitating pain, and made me enjoy the least humerous of SNL episodes.

After stopping the dilaudid pca, the equivalent of 6 is barely enough to hold you more than 3 hours. Despite the intense pain, I made it out of bed three times to walk around. While I suppose pain management could be better, this is the quickest path to recovery.

I cannot imagine how much worse this must be for those who do plif only; while the combination alif/plif has additional risks, if the lower back musculature was disturbed further I doubt I would be able to type this.

Till day 3....

Day 1 is almost over

What a rude awakening it was. Finding out that your tolerance to narcs is much higher than most, right after surgery, is far from pleasant. Luckily they were fairly quick about it, and within an hour I was better and remained extubated. This was puzzling since I so rarely take anything other than ultram.

So day 1, like expected, was rather unpleasant, though having gotten up and walked 15 feet I feel better about the whole thing.