Sunday, August 10, 2008

Dealing with the Damage

In 2005, I made a comeback into the sport of triathlon. I had yet to do an Ironman or half Ironman for that matter and before I got too old, I wanted to be able to check this event off my “to do” list. I took it much further than I had dreamed, and that one Ironman turned into three including two World Championships in Hawaii. In 2007, I was top 10 in my age group there. If I never do a triathlon again, I would be satisfied. It’s been a good run.

I have been training consistently for three and a half years without illness or injury but this year things have not gone so well. Multiple aches and pains have caught up with me. For the past year and a half, I have been dealing with discomfort in my right knee, which, in the past, I was able to endure and train through.

After the Buffalo Springs triathlon last month, the pain in my knee became too much to bear and I was unable to run without an abnormal gait. When the pain became constant, I put the running on hold and started swimming exclusively to see if it would go away, it didn’t, and I feel it actually worsened. I sought orthopedic attention and underwent arthroscopic surgery this week on Thursday 8/7.

I had my surgery done at a local outpatient surgery center here in Tulsa. I used to supervise the nurse anesthetists here so I was familiar with the staff and the routine there. I worked until 10:30pm the previous night and the last case of the evening I did was an emergent incision and drainage of a large back abscess on an obese diabetic man. It was disgusting. We sucked two liters of pus out of it. Needless to say, I was happy that I had chosen to have my surgery done at a clean new outpatient center. The last thing I needed was a nocicomial (hospital acquired) infection.

I arrived at the surgery center at 9:30 am the next day, and filled out the last set of paperwork including living will forms. I planned to have this surgery done under local anesthetic and MAC (monitored anesthesia care)…awake, so this seemed to be a little much. Tim Davis, a friend of mine, texted me on my phone and claimed my bike if I died. I texted him back and told him that bike was his if I didn’t survive.

I was quickly escorted back to the holding area where I received the standard issue a gown, hat, booties, and was placed in bed number 4. There, I got my IV and passed the time by watching my own personal TV where I caught up on details regarding the Brett Farve trade. I hope it works out for him in New York.

I had many visitors by old friends and folks that I used to work with. A surgery center like this is a great place to work. There is no call or weekend duties and the patients are healthy, unlike the major tertiary center where I work. Many nurses move on to places like this, it’s a much better lifestyle.

Pat Case is a nurse anesthetist that I used to supervise and she arrived there early and signed up for the room that my case was to be assigned. Pat is an avid cyclist and is fluent in Italian. She has a second home in Italy, and has ridden most of Italy’s major mountain passes. Pat has even been to the Tour de France. She would always have a copy of Velo News in her bag that I could read when I was working with her. I was pleased that she would be taking care of me.

Dr Ron Hood was my surgeon. He trained in San Francisco with Eric Heiden, the former uber Olympic speed skater and professional cyclist, who is now an orthopedic surgeon. Ron is an expert on knees and sports medicine. I liked the way that he was able to do a good local block to allow the patient to stay awake and watch the surgery. It was what I wanted. The post op pictures just don’t show the knee as well as a dynamic live view.

I was taken into the room and hooked up to all the monitors. I requested not to get any Versed (Midazolam). It is a potent fast acting benzodiazapine, which causes amnesia. I usually give this as my pre-anesthetic and can quickly convert a stressed person into a laughing jokester. It is known as truth serum and is often used illegally as a date rape drug. It has a half-life of 2 hours but I had no idea how I would be affected by the drug. I wanted to remember the procedure so I opted not to have it.

When the scrub tech pulled up some local anesthetic in a 60 ml syringe with a long 18-gauge needle, I asked Pat “I think I’ll take that Fentanyl now“. Fentanyl is a fast acting powerful opioid, which is ten times the potency of morphine. I observe patient’s reactions daily as I administer it, and often wonder what it feels like. It is a frequently abused drug in our profession. I soon found out why.

I felt a lightheaded and a warm euphoric feeling came over me soon after I got it. It was smooth. The next drug I asked for was Diprivan (Propofol). It facilitates inhibitory neurotransmission in the brain mediated by a transmitter known in short as GABA. It often burns as it flows into the vein then it renders immediate unconsciousness. I was commenting on the lack of the burn when the next thing I knew; Pat was quietly speaking my name and waking me up. I opened my eyes, I looked up to the screen, the scope was in my knee, and the surgery was already in progress. “Wow, how long was I asleep?” It’s been a while since I have had anesthetic and each time I marvel at the power of these drugs.

Ron quickly went over his findings. Immediately, he said they found cartilage loose bodies floating around in the joint. There was a tight plica stretched across my lateral femoral condyle digging a groove into it. He demonstrated the damage with instruments. I had a torn lateral meniscus and my lateral capsule demonstrated some tight bands causing my patella to track laterally. The photo shown below is the synovial plica which was removed and causing the problems.

Loose cartilage body

Lateral Meniscus tear

Femoral cartilage groove

I had no pain during the procedure and I asked questions just as I would have if I was sitting back there administering the anesthesia.

The lateral plica is a rare finding. Most plicas are medial. The most likely cause of lateral plicas is trauma or overuse. He said he had never seen anything like it. After he pulled it out, I looked at it. It had the consistency of ligament and I knew that it was the source of my pain. It had gradually gotten thicker, tighter and tougher and had begun to wear a groove into my femoral cartilage as a steel cable would if it were rubbed repetitively across a piece of wood.

He trimmed up my lateral meniscus and did a lateral release of the tight capsular bands and I was done. Here is the trim job ----->

I was taken to the recovery room where I was greeted by recovery nurses, Lacy and Kelly. They were familiar faces that I usually drop patients to in the hospital after they awake from anesthetics. They had moved to outpatient too. Dana eventually was allowed back into recovery to be with me. I am normally reserved guy but the Fentanyl made me euphoric and I wouldn’t shut up. Dana had to tell me to put a lid on it. The cardiac alarm above my bed was going off because my heart rate was extremely bradycardic at 38-39 bpm and it was causing a racket. I’m sure that they wanted to get me out of there.

Lateral capsular tight bands

I was discharged quickly with crutches, a large portable ice cooler attached to a knee wrap, which was great. I didn’t need to take any pain medication and my knee felt better after surgery than it had before. This was a good sign. The referred pain, which radiated into my calf, had also disappeared.

I was able to go to work the next day on crutches. I arranged a long room where I could prop my leg up and ice my knee. I brought my knee cooler with me.

Recovery is going well. I might start swimming again on Monday and then in two weeks or so, I will be able to get back to cycling. Meanwhile, I think I will take a break and watch the Olympics. It’s a good time to be laid up. It’s nice to have some motivating TV to keep me off my feet and keep me entertained.

I am so glad that I made the right decision to go through with taking care of this issue now. It’s a relief to know that the source of my discomfort is resolved. Maybe it isn’t all over for me. I plan on a smart recovery and focus on next season. I look forward to the journey back.

1 comment:

Jennifer Harrison said...

Rob! Wow, those pics are AWESOME and it was very fascinating to see the actual damage. SPEEDY recovery to you! Jen H.