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!

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