On the Third Day

Day 4 post op. Well it is barely day, Two thirty in the morning is day but certainly not daylight and it still feels like night, I am awake and feeling very unwell. I am nauseous, clammy, sweating profusely and I am in pain. I do not know what is wrong with me but I have a pretty good idea. If I were not in so much pain it would be easier to think.

I manoeuvre myself out of bed. The shoulder is sore but my feelings of being unwell are unrelated at least in a direct sense, to my shoulder. My shoulder just adds a complication as it is very hard to get comfortable and move around freely. Even rolling up into a ball is not readily possible. The need to go to the toilet is upon me but when I sit, the feelings of unwellness increase and there is a pain inside me when I push that is what I could imagine would be the sort of feeling I might have if a King Arthur type sword had been inserted into my bum. It is sharp, intense, worrying and the waves of nausea are creeping over me in earnest. What am I to do?

I know intrinsically my unwellness is due to my bodies reaction to itself. There is too much of myself within me and it is making me sick. I need to shit. However the pain when I try is immense so damned if I do and dead if I don't. Oh happy days!

The problem with working in a healthcare environment is you can know too much, or have heard too much. This can really fan the fire of worry and dread. If I go to the hospital what are they going to do?  I can tell you straight up, they are not going to treat it as seriously as I want them to. I will have to wait in the waiitng area and who knows how long that will be for. It is not like I have lost a limb or have an ice pick sticking out of my head. I feel like I am dying and if that is how the cookie crumbles, I would rather have some semblance of dignity by dying at home. I have never felt this bad and in such pain in trying to do something about it,  than I have ever felt before.

I had started to go down hill on Day 3. I had a mild awakening to the problem that was now causing me distress. I had calculated it was three days since I had gone to the toilet which was concerning for a regular as type of guy. However, I had heard stories of much longer and the ones I had witnessed in the operating room, the ones with a genuine bowel blockage, were often well over this time.  Luckily I had found some Movicol in the medicine cabinet. The instructions were vague.

" Take one sachet with water daily increasing to up to 8 satchets if needed."

 Over what sort of time frame please. If I build up at that rate it will be a week or so before I might go naturally! So after an initial sachet, within a few hours I took seven more and hang the consequences. This was going to end badly I knew it.

Mechanical removal. Enemas, Flushing. Operations to look for bowel blockage and the reason. I had heard people speak butm the talk now sounded frightening. It is always okay when it relates to someone else but to me? I had had a hernia operation  a few years back. Maybe coincidentally I did have a blockage from post operative adhesions? Oh, the pain and the shame. I knew these people. And how would I get on having to cope with a stuffed shoulder at the same time.

I wandered around drinking water, trying to sit every now and then but always met with the sharp pain inside me.

My wife woke at five am.. Thankfully I was now not alone.

" You look terrible. I am getting dressed and we are off to the hospital!"

OIC: Opioid Induced Constipation. A phenomenon which is well documented and one which  I could now add  to the list of illnesses, conditions and other medical ailments that I had endured in my life time. It was one that had caught me unawares. Mr Organised, Mr Planning had come a cropper. Mr Think Ahead was now in a right state and the answer required to rid me of the evil was overdue. Action was required now or the consequences were not going to be good.

Through clenched teeth and with  an agonised face I said I would be alright for the time being. I was not being cute or casual or brave. I did not want to endure whatever they might have for me at the hospital and I still had not given up hope of a home birth.

My wife suggested drinking warm water, which I did, in the words of Cyndi Lauper, " Glass after glass."

I had tried to sit on the toilet numerous times but this time I was determined. The complicating factor was Elvis Presley died on the toilet. He had underlying issues for sure but it was the toilet that finally got him. One should not push hard on the toilet. It does terrible things to your blood pressure and bad things to other things in that area. I have had a coronary stent so issues with the heart are near and dear to me.But if this was how I was going to leap off this mortal coil, so be it.

I sat, sweated and tried a little, increasing in intensity progressively until I was trying a lot. And then it happened! Let's just say I am still here and it took a whole day of repeated visits to the loo to clear the log jam but eventually I got there and felt bloody amazing once again!

The opioids given to me to keep the pain at bay for my shoulder gave me wonderful pain relief and really were fantastic. I had been warned about constipation but as a warning, with no practical advice on what to do, I let my guard down. The breakfast menu in the hospital had prunes on it amongst other things. I should have had these perhaps. I should have taken foods into the hospital that might have helped e.g dried fruits, dates, prunes, kiwifruit. I should have had a plan. I should have considered the possible complications. So many shoulds. I let my guard down. It won't happen again!

The breakfast menu has options that might have been better than going for the luxury what I seldom get at home choices!

The medicine cabinet is now complete with things to help including the last ditch suppositories. Once you are in a state of being bunged up, eating a few prunes is not going to help. The pain is unbelievable and at least a suppository beats cutting one's own guts open to remove the offending blockage. Yes I had contemplated that as a last ditch thing.

Shoulder operations involve pain. I had been assured of this fact and luckily the team looking after my well being had provided me with enough chemical means to combat pain to a very good extent. The positives out weighed the negatives but if anyone is steered away from the abyss by being forewarned and therefore prepared, the bullet you have dodged is indeed silver.

One armed and dangerous

The operation got under way at two o'clock. My last memories were from shortly before.

My anaesthetist had given me a block whereby local anaesthetic is injected in and around the area where  the nerves that control the arm.are located. This ensures the arm is numb for at least twelve hours. If it works that means little or no pain in the immediate post op period.. Yahoo!

I woke in my room with a dead cold ham on my chest. Aargh! I had not felt I needed to stand out from the crowd by advising them I was pretty much vegetarian but was this some kind of sick joke?Could my family or workmates have planned such a prank?
Well the cold ham turned out to be my own "dead"arm.  Quite disconcerting in some ways but the lack of pain was great. I too felt great. The arm slowly melted after twelve hours but was still pretty dead at the eighteen hour stage. Wow!

I rearranged the bed slightly to get into the recommended half sitting beach chair position and arranged a pillow to support my injured arm at the elbow. Next of course I texted my wife to let her know all was well. I had "banned" her from hanging around for the operation and then being there afterwards, Dozy patients after surgery are hardly the life of the party and we live an hour out of town and have animals to care for. She would come the next morning to collect me.

There is no point recalling in a "My Diary" sort of way the events of the night or of the morning. However I will note a few points I think are of interest;

• A nurse came to see me regularly with pain relief even though my arm was good. This was to help my body get on top of the pain before the block had worn off.  They were important to have even though the need for additional pain relief at that time was not there. " Drink plenty of water. These medications can cause constipation". So I did refilling my drink bottle from the tap throughout the night. I had a reasonably fitful night but hey, who cares? I had time off to recouperate afterwards, I had my MP3 player loaded with music to listen to and good headphones, I had TV and the sport was on, I had a pen and paper and the desire to learn to write left handed legibly. What more could I want? I got up regularly for more water and to go for a walk around the ward. Exercise gets the blood flowing and helps reduce any chance of developing a clot. It also meant I could make myself a few cups of tea. Luxury!
• Unfortunately hospital food fills a hole but I would hardly say it is overly nutritious. Frozen vegetables boiled to death, they always seem to do that.. But we are in a hospital not a hotel. This is always to be remembered. If there is a next time, I would have packed some fruit and a few snacks. The importance of this will be revisited at a later time, and I was totally unprepared for the consequences!
• Always check  or ask what treatments you are being given. It keeps you involved, it is another check the medications are correct and seriously, you need to have some responsibility for your own care. The medications I was given this time were all correct and in line with exactly what I had been told to expect. However,when my last nurse of my total visit mentioned something in passing, it had never been noted on the notes for my admission that I had a coronary stent in place. She was gobsmacked and as I said, have some responsibility for yourself. It might really pay off.

• Pain

• Importance of Controlling Pain

  Inadequately managed pain can lead to adverse physical and psychological patient outcomes for individual patients and their families. Continuous, unrelieved pain activates the pituitary-adrenal axis, which can suppress the immune system and result in postsurgical infection and poor wound healing. Sympathetic activation can have negative effects on the cardiovascular, gastrointestinal, and renal systems, predisposing patients to adverse events such as cardiac ischemia and ileus. Of particular importance to nursing care, unrelieved pain reduces patient mobility, resulting in complications such as deep vein thrombosis, pulmonary embolus, and pneumonia. Post surgical complications related to inadequate pain management negatively affect the patient’s welfare and the hospital performance because of extended lengths of stay and readmissions, both of which increase the cost of care.
  Reference: Chapter 17Improving the Quality of Care Through Pain Assessment and Management
  by Nancy Wells; Chris Pasero; Margo McCaffery.from the book:Patient Safety and Quality: An Evidence-Based Handbook for Nurses
• Pain needs to be assessed. There is no pain-o-meter or something that can be placed under the tongue to determine the amount of pain someone is experiencing. Patients can assess their own pain as they are often asked to do." Given that unbelievable pain is 10 and no pain is 0, what number woudd you give your pain?" However people perceptions of pain vary widely as do the perception of the nurse taking the information. It is not hard to see when someone is in real and severe pain but after that it comes down to a personal analysis which gives rise to error. There have been a multitude of studies into pain relief. These studies and others suggested that when patients had moderate to severe pain, they had only about a 50 percent chance of obtaining adequate pain relief.
• So back to me. Remember this is all about me. I had been warned shoulder surgery is painful. My clinicians were aware of the fact and I had the block just prior to surgery to give me a good amount of post surgical pain relief. They started oral medication when I was yet to be sore to ensure they were on top of the pain before any chance of breakthrough pain raised its ugly painful head. I was provided with a script for some reasonably powerful pain medication to last me through my first days at home. To be honest, there was pain but it was manageable. I have had back surgery previously and compared to back pain this was a walk in the park! Don't worry your body lets you know pretty quickly when it doesn't like something but change what or how you are doing something, obey instructions, do as you are told with post op exercises and take your medication as advised and you will be fine.
• However, nothing could have prepared me for what happened next. I thought I was going to and I wished almost that I could, have died.

Last preparation and hospital

Operation Day. The time is upon me. A few more minor details to sort out then in we go. First things first. I've got to tell you something serious. My wife and I are separating. Well just for a time. We are lucky enough to have a spare room with a bed so after my one night in hospital I will return to the spare room. There are a few reasons for this;

• It is my sword arm that is stuffed. I will not be able to brandish my sword to repel invaders. She is better off on her own.

• I usually sleep closest to the door. Apparently this is the norm and it is the right hand side of the bed, also the norm for the male. See point one. Sword arm stuffed. Any would assailants will at least have to grope around the empty side and give me enough time to make my way from the spare room to repel them. Hey two beds might even confuse them!

• A survey reported in the Daily Mail in 2011 of 3000 adults found that 30% of  those who slept on the left hand side of the bed woke happier and feeling more positive for the day compared to only 18% of those that slept on the right side of the bed. I will need all the help that I can get!

• If I am rolling round in pain trying to get comfortable, the last thing I want is to cause sleep deprivation in my dear wife.

• It is recommended the arm that has been operated on should have some night time support in addition to the sling which is worn. I have set the bed up as shown in the photo below with a pillow for support. The towel can used to fine tune the height if needed. As it is my right arm, I have to take the left hand side of the bed. I just could not boot my wife away from her preferred side.

Note the pillow on the right to support the arm. The pillows at the back are to help maintain a slight sitting position.

Just a small point, the so called research on bed sides never mentions from which viewpoint does one decide which is the left or right hand side  Is it either a/ from looking at the bed from the bottom of the bed? Or is it b/ as if one were lying in the bed?  The fact this question was not addressed is why arts students should not report on anything scientific unless it is about how fluffy kittens are.

Luckily science is here to help us again. The left hand side of the brain is the side of reason, logic, mathematics and all the good stuff. The left hand side of the brain controls the right hand side of the body. There are few left handed scientists. The right hand side of the brain is more concerned with ideas, music, art, abstract thought and all that good stuff. The right hand side of the brain controls the left hand side of the body. Left handedness abounds in the world of the arts. Women have long been associated with music, dancing  and artistry through the ages. The left hand side of the bed is their so called correct side of the bed.

Anyway, enough about you. It is back to me and my impending shoulder operation and the descent into agony. Some more things to organise.

• Medications that you might be otherwise taking in original packaging

• Extra medication..wink wink nudge nudge.No I am not talking a hip flask. I was told by a nurse friend the hospitals are sometimes a little tawdry when it comes to handing out pain relief. I have chucked a few pain killers into the "just in case" section of my overnight bag.

• Loose open front style shirt. The arm is going to be sore, in a sling and not up to hands in the air throw a tight sweat shirt on technique.

• Radiographs / X rays. It is close to six since I had my consultation and diagnosis confirmed with the orthopaedic surgeon. The X rays and other imaging will serve to remind him of the injury and are often used as a road map during surgery to ensure they are in the best place to treat the injury.

• Book

• MP3 player with headphones. If I am awake in the night, I want to be prepared!

I have been fasting since midnight. I have bathed with a surgical scrub soap. Let battle commence!

Preparation: Life without an arm

The date of the surgery to clear away the bone in my shoulder and repair the tear to the supraspinatus muscle is booked and we now move to count down mode. There are things to consider. These points of consideration revolve largely around losing the use of one arm for six weeks. Toileting, dressing, sleeping, caring for the house, eating, so many things, are going to become troublesome. Preparation will at least head some things off at the pass and make life a little more tolerable.

I make a mental list;

• No use of the car.
• Middle of winter so firewood needed and in reasonable proximity to the house. 
• How to use the computer?
• What do I need to get down from anywhere that I might require?
• Getting dressed and undressed are there any issues?
• Toileting?
• Eating?

I am lucky I am married: Not just lucky but extremely lucky to share my life with a warm hearted, capable, giving woman whose only flaw is  she had the weakness to marry me.  Oh well, lucky me again!

Transport as needed will be fitted around when my wife can drive me.The pain will stop any thought of hopping in the car plus the fact that should anything happen, there would be no insurance . Should an injury to another person arise whilst driving, it would automatically be a criminal matter. Sometimes one has to be serious. In Australia it is illegal to drive whilst one's arm is in a sling.

Firewood: Australia, the sunburnt country for sure but it can still get damn cold in winter. We live on the tropical Mid North Coast but in the mountains bordering this paradise, minus 8 is possible during the Winter months. Get organised!

The computer: What a great time to be alive so that when a home bound incapacity strikes, the world is still at your fingertips! Firstly I changed my mouse setting so the right hand click is the main click and I immediately start using my left hand to operate it. It feels funny at first like anything different but it doesn't take long to feel okay.

I try the voice recognition program built into Windows these days. After many sessions I give this up as a bad joke! It certainly never got the stream of swear words right that I leveled at it!

I purchase a stand up / sit down workstation. I really don't want to be totally inactive whilst recuperating and the arm sling would be in the way too.

 Getting down what is up high: A simple skirt round the house both inside and out meant I moved a few things around.  Pretty simple but glad I did it.

Dressing: A friend and I were having a laugh at work one day and I surmised our management were so stupid I bet they would be wearing shoes that had no laces as they would have difficulty tying them. We got a few more guffaws out of that one as after some surreptitious foot gazing it turned to be true!

I like to walk but I could see getting shoes done up was going to be hard and whilst my wife is wonderful, one cannot spend all day squawking like a baby bird to be fed.

I also purchased a few extra loose fitting open down the front shirts. T shirts and anything that requires over head donning is not going to cut the mustard.

Toileting: I will grow a beard! Beards are back in vogue despite my wife's protestations!  I have an electric toothbrush.

Food: I am not a fan of any prepackaged food. I use good fuel in my car so why would I eat shit when it comes to my own refueling?  But that is me. So I make up some soups and meals and put these in the freezer for lunches. Okay, there are a couple of tins of soup and baked beans there if I get caught.


And that is that. There will be a little more prep just before surgery but we will deal with that then. Even with a crook shoulder you can still shoulder responsibility!

Man down, shoulder overboard!

Let us review a few relevant pieces of information. It has got to be done before we can get down to the good bits that may be useful. Sad but true.

  "If you don't eat your meat, you can't have any pudding. How can you have any pudding if you don't eat your meat?" Pink Floyd

Requirement:

Shoulder Surgery to remove bone from the acromion and repair the rotator cuff.

About the patient:

Male, 61 years of age, physically demanding job with above shoulder height work. Physically active. Right hand dominant. Gorgeous ( not from the doctor's notes but implied).

Mechanism of injury:

"Whilst he was at work he was moving a patient off the operating table onto the  patient bed with all the necessary precautions, when he felt a twinge and pain over the anterior aspect of the right shoulder. He reported this to his employer but continued to work.On the same night and particularly the next morning, he developed significant and severe anterolateral shoulder pain associated with difficulty of elevation of the arm. Particularly troublesome at night."

Tests ordered:

X ray and ultrasound: Xray shows the bone with a bony irregularity on the underside of the acromion. The ultrasound clearly shows a full thickness, full width tear of the supraspinastus.
 As the diagnosis is quite clear no MRI was ordered. Range of motion tests were carried out in the doctors room. There was a full range of motion but with pain.

Other points of note:

Country where this is taking place. is Australia, in the small regional town of Coffs Harbour.
As the injury happened at work, the surgery will be covered by workers compensation.The significance of this last point will be covered in a future blog.

X ray of my right shoulder. The bone at the very top, bright white in the main is the clavicle. The gap is the acromioclavicular joint. Passing over the gap you come to the acromion which is the end of a long bony process that starts with the scapula or shoulder blade.. You can see a small bur of bone on the underside of the clavicle  and some extra bone in the acromion which rubs against the supraspinatus muscle that runs though that gap.

So let's just break this down a little. What does it all mean?

The shoulder is any amazing joint. Your hip joint is a ball and socket joint. There is a lot of stability in the ball and socket joint. Your knee joint is set up for the basic motion of walking. The shoulder joint is almost a flat joint with little intrinsic stability in the joint itself. But look at what you can do with your arms; up high, down low, rotate them, cross over your chest, scratch your back- a huge range of motion. What permits all this is a group of muscles that connect around the shoulder to the humerus. This group of muscles forms the rotator cuff. Over lying that is more muscle, predominantly the deltoid.

If you do too much, muscles fail. Things wear. If you do a lot with your arms through sport or your job it stands to reason you are going to wear out earlier. Age changes structures and in the body, not much gets better with age, let's be honest. 

So without going into a full on lesson into the intricacies and issues of the anatomy of the shoulder and all that can go wrong with it / them, there are failures in the structures. Hey life ain't perfect. Perfect in it's imperfection.

There are plenty of web sites that can cover anatomy and shoulder problems if these interest you. 

But here is the rub,  A study looking at the shoulders of a group of deceased males found 70% had rotator cuff tears. It is thought that tears are just a natural occurrence as a result of the aging process and are often asymptomatic or at least with few symptoms. Therefore unless the  patient is young, is working in a physically demanding occupation and is experiencing undue discomfort, surgery is not routinely required. There are conservative treatment options that can help instead.

At 61 years of age, I am considered young. Hey, that's a bonus. I have had pain and if I get back to it at some stage, my work is physically demanding. I am having surgery. That really is what the blog is about.

One final point I discovered in my search for answers, was the amount of pain a person suffered as a result of a failure in some way of the shoulder, had no correlation to the amount and nature of  the damage. In other words listen to your surgeon and let them tell you what is best for you.

Getting the Low Down on Shoulder Surgery.

The nutshell edition goes like this. Hurt shoulder at work, went to doctor who referred me to an orthopaedic surgeon who after imaging confirmed I needed surgery to fix my ailment. There were a few extra bits like pain, off work , pain and a long road back oh and not to forget, pain.

Here endeth the blog!

Life is so simple when you go for the line drawing version. The trouble with me, and there are plenty more like me around, I like to know. I want the three dimensional vivid oil painting version. In my minds eye, it looks better.

I like to know in this case:

what is the problem, 

how did it happen,

could I have avoided it,

what is involved in the repair, 

what if I don't have repair, 

how much will it cost in time and money,

what is going to happen with my employment, 

what is going to happen at the hospital, 

what is rehabilitation going to involve,

what can I do, 

what cannot I not do????

That is for starters. The entree, main and dessert course questions have not arrived yet. But they will and they do.

And, the funny thing about wanting to know, is you want to know some truth. Opinions can help formulate  truth, lots of opinions help to hone that down to nuggets with value. But in the end the only real truth is in your own experience. You can anticipate and prepare for the experience but most of the truth comes after the experience.

The other consequence of wanting to know and going searching for some answers, is you know someone else like you somewhere is also looking for answers. To share the hours of picking through the rubble to find useful pieces just seems like the right thing to do. I will tell you now I learnt some things I never read about or was never told about.

Over the next period of time, I will share my experience with shoulder surgery which involved a sub acromial decompression and rotator cuff repair. I will cover the questions as outlined and provide my real life experience. For the fact finders out there there will be something that you will glean that you will not find anywhere else.  I know that because I looked.