Thursday January 29 was the two-week mark after surgery, and I had an appointment with the surgeon (whose office is an hour away from my home) to check in and have the staples out.
Dr. Smith was boyishly pleased by my progress and by the X-rays, which he insisted on showing me, over my protest, so I could tell him yet again how clever he is. (This man is 67 years old, so this is a second or third boyhood.) I find his transparent delight rather charming, and I told him how positive the message he sent just before surgery was.
The X-rays weren't really all that bad. I realized that the picture in my mind bore more resemblance to a crankshaft complete with connecting rods than to reality (in effect, metal caps on both the bones involved, plus, I assume, some connecting mechanism that doesn't show up on X-ray).
As for progress, I'm off the cane (which is a lot more trouble than it's worth) and I can walk without a limp. In fact, I was limping more before surgery than I am now.
Staples. These are literally staples, like the ones you'd use on a stack of paper, except bigger, and except that they don't bend down at the edges inside but just sit there. (Maybe they bend out. I'm not sure.)
I am told that the advantage of staples is speed of wound closure, and I am further somewhat piously told that this is important so that the patient is not under general anesthesia for too long. I'm suspecting, however, that the real reason is that the surgeon, having performed the interesting parts of the surgery already, is now bored and wants to get out of there ASAP.
The disadvantage is that having staples removed hurts. Quite a lot, actually, though Nevada, the nurse/ administrator, who removed them, was certainly as gentle as possible. Furthermore, the ends tear the sides of the incision as they are yanked out, which doesn't seem optimal to me. (!!)
Oh well. The incision is now held together with steri-strips, which will come off in their own time. The scar will not be attractive, but who cares.
Wednesday, February 4, 2009
Tuesday, January 27, 2009
High-tech
When we originally - that would be last November - discussed this surgery with Dr. Smith, we found him to be a vigorous advocate of a computer-assisted laser-driven positioning device, whereby the new implant could be set in exactly straight to within a millimeter, level with the ground in all dimensions. This is best, I was assured, and that sounds sensible to me.
I had assumed that all the top-notch people were now doing it this way (as opposed to the previous system of jigs plus instinct), but apparently not. My physical therapist was puzzled by the two little holes in my thigh and also on my lower leg, and asked if they were drains or something. No, I said, that's where they mounted the lasers to signal this positioning system. She sees a lot of knee replacement folks, and she'd never seen this before.
I did a Google search, and this thing has been around at least since 1995, though most of the articles on it are in expensive medical journals where you can't get at them.
My surgeon is in love with this thing. He claims it's revitalized his entire practice, and this enthusiasm explains that big grin in the OR. I can see that. Not only does he get to play with a lot of very jazzy equipment, he now has the tools to get a much better result more reliably.
God alone knows, of course, what the equipment costs. [Note: today (1/29) I found out what it costs. The software comes in at $400,000; they "give" you the hardware with the software. There must be some reason for this odd pricing; I'm suspecting some tax reason. The software, like all software, is subject to update, for another fee, of course. Not really as much money as I thought.] Somehow someone or other talked Mills Peninsula Hospital, a tired old hospital (more on this later), into springing for this thing. I am told that knee replacements are big money-makers for hospitals, at least compared to the uncompensated care they're required to provide to a lot of people (anything's a profit center compared to that!), and since patients like me have a lot of alternatives about where to go for this surgery, and indeed, whether to have it at all (it's "elective" surgery, your other choice being to be in constant pain I guess), having the Snazziest Equipment is doubtless intended to be a selling point.
I'm not qualified to evaluate any of this. That's what I hired the surgeon for. If he says it's better, and if the proposal doesn't offend common sense, then I go with that.
Again, cost. Are they going to hit me or Blue Cross or both of us up for being yet again on the cutting edge? Well, yeh. Of course. The only question is, where will this expense be hidden in the bill, and what would the alternative cost?
And what am I willing to pay for a shot at a better result? Name your figure, people. Anything even remotely within reason.
I had assumed that all the top-notch people were now doing it this way (as opposed to the previous system of jigs plus instinct), but apparently not. My physical therapist was puzzled by the two little holes in my thigh and also on my lower leg, and asked if they were drains or something. No, I said, that's where they mounted the lasers to signal this positioning system. She sees a lot of knee replacement folks, and she'd never seen this before.
I did a Google search, and this thing has been around at least since 1995, though most of the articles on it are in expensive medical journals where you can't get at them.
My surgeon is in love with this thing. He claims it's revitalized his entire practice, and this enthusiasm explains that big grin in the OR. I can see that. Not only does he get to play with a lot of very jazzy equipment, he now has the tools to get a much better result more reliably.
God alone knows, of course, what the equipment costs. [Note: today (1/29) I found out what it costs. The software comes in at $400,000; they "give" you the hardware with the software. There must be some reason for this odd pricing; I'm suspecting some tax reason. The software, like all software, is subject to update, for another fee, of course. Not really as much money as I thought.] Somehow someone or other talked Mills Peninsula Hospital, a tired old hospital (more on this later), into springing for this thing. I am told that knee replacements are big money-makers for hospitals, at least compared to the uncompensated care they're required to provide to a lot of people (anything's a profit center compared to that!), and since patients like me have a lot of alternatives about where to go for this surgery, and indeed, whether to have it at all (it's "elective" surgery, your other choice being to be in constant pain I guess), having the Snazziest Equipment is doubtless intended to be a selling point.
I'm not qualified to evaluate any of this. That's what I hired the surgeon for. If he says it's better, and if the proposal doesn't offend common sense, then I go with that.
Again, cost. Are they going to hit me or Blue Cross or both of us up for being yet again on the cutting edge? Well, yeh. Of course. The only question is, where will this expense be hidden in the bill, and what would the alternative cost?
And what am I willing to pay for a shot at a better result? Name your figure, people. Anything even remotely within reason.
Sunday, January 25, 2009
The cutting edge, a bleeding tale
Let's talk about medical advances.
One of the risks of total knee replacement surgery is deep vein thrombosis ("DVT") afterwards, in which a blood clot forms in the calf and then migrates to the lungs or the heart or the brain - there's no real good place to have one.
To prevent this event patients are routinely given anticoagulants after surgery. I take it that these medications thin the blood, make it less likely to clot and therefore less likely to form a DVT. I have no idea how they work.
Lovenox is such a drug, and is taken by self-administered injection. They showed me how to do this in the hospital. All the muss and fuss have been taken out of this procedure. One is given an already-loaded syringe with a thin needle about an inch long. After swabbing abdominal skin with alcohol (they give you the swabs too, in little packets) you pinch up some skin and just jab the thing straight in. (No, surprisingly, it doesn't hurt.) Push the plunger all the way in, pull the thing out, push a little lever which shoots a plastic protector around the needle, drop the whole thing in a sharps disposal container. Once a day for ten days after coming home.
The list price is $200 per shot, for a total of $2,000 for a course of treatment. This is clearly off the wall, and Blue Cross of course has no time for this nonsense. There is, however, a $200 co-pay, again for the whole ten days.
So I called the doctor to ask if this trip is really necessary, and he said that there are lots of anticoagulants, notably coumadin aka warfarin aka rat poison. This stuff has been around since the early part of the last century, and is cheap as dirt.
So why are we using this pricey stuff? Because getting the dosage right for coumadin is a hassle. It requires several blood tests, and that they fiddle with it a lot. He got two sentences into the explanation and already we'd used up $200 of my attention. I have no idea whether the drug itself in Lovenox is better at its job than coumadin, but I can tell you that the dosage and delivery systems are far superior. The last thing I wanted to do at that point was tour all over the landscape having blood drawn.
So, if I were Empress for a Year and running the newly fixed American health care system, would I opt for coumadin or Lovenox in this situation? In the coumadin scenario, remember, although the drug iself is cheap, that's not the end of the story, it takes up the time of professionals to draw the blood and fiddle with the dosage, and that costs money too, of course. Would I require patients like myself to pay extra for convenience, or would I just say, "The heck with it, give everyone the little syringes and move on"?
As we dig a little deeper here, why is Lovenox so expensive? Is it made of ground up grass seeds from an itty-bitty grass that grows only in Siberia or something? Of course not. It's expensive because the drug company that holds the patent is sticking us up (or, legitimately trying to recover development costs, your choice) in preparation for the day when Lovenox goes out of patent and can be manufactured in generic, at which point the price will drop.
Does this make the drug company a bad guy? Not necessarily. Whoever they are, they had to do a lot of development and testing on this stuff, along with a lot of other stray ideas that didn't come to anything. They put this money in because they hoped to make a profit if Lovenox panned out. If we expect them to continue to do all this R&D we have to reward them with some profits when things work.
In the big picture, Lovenox is an improvement. Effective and easy of dosage, no muss no fuss. I don't much like sticking myself with needles, but I'm getting over it. Is it essential? Probably not, we could lump along with warfarin perfectly well, but isn't improvement in care desirable? I think so.
I don't know the answers to any of the questions I've proposed. And if you'll excuse me now, I have to go stick myself with a needle.
One of the risks of total knee replacement surgery is deep vein thrombosis ("DVT") afterwards, in which a blood clot forms in the calf and then migrates to the lungs or the heart or the brain - there's no real good place to have one.
To prevent this event patients are routinely given anticoagulants after surgery. I take it that these medications thin the blood, make it less likely to clot and therefore less likely to form a DVT. I have no idea how they work.
Lovenox is such a drug, and is taken by self-administered injection. They showed me how to do this in the hospital. All the muss and fuss have been taken out of this procedure. One is given an already-loaded syringe with a thin needle about an inch long. After swabbing abdominal skin with alcohol (they give you the swabs too, in little packets) you pinch up some skin and just jab the thing straight in. (No, surprisingly, it doesn't hurt.) Push the plunger all the way in, pull the thing out, push a little lever which shoots a plastic protector around the needle, drop the whole thing in a sharps disposal container. Once a day for ten days after coming home.
The list price is $200 per shot, for a total of $2,000 for a course of treatment. This is clearly off the wall, and Blue Cross of course has no time for this nonsense. There is, however, a $200 co-pay, again for the whole ten days.
So I called the doctor to ask if this trip is really necessary, and he said that there are lots of anticoagulants, notably coumadin aka warfarin aka rat poison. This stuff has been around since the early part of the last century, and is cheap as dirt.
So why are we using this pricey stuff? Because getting the dosage right for coumadin is a hassle. It requires several blood tests, and that they fiddle with it a lot. He got two sentences into the explanation and already we'd used up $200 of my attention. I have no idea whether the drug itself in Lovenox is better at its job than coumadin, but I can tell you that the dosage and delivery systems are far superior. The last thing I wanted to do at that point was tour all over the landscape having blood drawn.
So, if I were Empress for a Year and running the newly fixed American health care system, would I opt for coumadin or Lovenox in this situation? In the coumadin scenario, remember, although the drug iself is cheap, that's not the end of the story, it takes up the time of professionals to draw the blood and fiddle with the dosage, and that costs money too, of course. Would I require patients like myself to pay extra for convenience, or would I just say, "The heck with it, give everyone the little syringes and move on"?
As we dig a little deeper here, why is Lovenox so expensive? Is it made of ground up grass seeds from an itty-bitty grass that grows only in Siberia or something? Of course not. It's expensive because the drug company that holds the patent is sticking us up (or, legitimately trying to recover development costs, your choice) in preparation for the day when Lovenox goes out of patent and can be manufactured in generic, at which point the price will drop.
Does this make the drug company a bad guy? Not necessarily. Whoever they are, they had to do a lot of development and testing on this stuff, along with a lot of other stray ideas that didn't come to anything. They put this money in because they hoped to make a profit if Lovenox panned out. If we expect them to continue to do all this R&D we have to reward them with some profits when things work.
In the big picture, Lovenox is an improvement. Effective and easy of dosage, no muss no fuss. I don't much like sticking myself with needles, but I'm getting over it. Is it essential? Probably not, we could lump along with warfarin perfectly well, but isn't improvement in care desirable? I think so.
I don't know the answers to any of the questions I've proposed. And if you'll excuse me now, I have to go stick myself with a needle.
Saturday, January 24, 2009
One way to get well
There's physical healing, but you know, my knee didn't just walk into the doctor's office by itself. Emotional and psychological healing are important too.So since all our cars are more or less junkers and/or hard to get into or out of, we rented a pretty snazzy late model sedan for the weekend, at my husband's suggestion, and took a long drive today. To Pescadero, out on the coast.
Now back in the day, 35 years ago give or take, we used to hang around Pescadero a fair amount, and especially at Duarte's, the town bar. (It isn't much of a town, but it's a heck of a good bar.) Duarte's has been there since the late nineteenth century, pretty much in the form it was in in 1975. Of course I assumed it would have been changed all out of recognition since then.
Pleasant surprise time! The place might as well have been put in a jar, along with the whole rest of the tiny settlement. The same family is still running Duarte's, courtesy of Cindy Duarte, fourth generation, and they still serve artichoke omlets!! Of which I had one, and a couple glasses of wine, and felt pretty good.
Now I hobbled all over on crutches, and didn't keep my leg elevated, and drank wine when I probably shouldn't, given the pain meds.
But you know what? My optimism, which had kind of flagged, was given a great big revival by this (actually quite short) journey.
The Surgery
Today is January 24, that would be nine days after surgery (January 15).I haven't been avoiding blogging about this experience, exactly, but I haven't exactly been rushing up to the computer either, as some of you have observed to me.
That's not because we got a bad outcome. The surgery was a brilliant success according to Dr. Smith, the surgeon, who came into my room the day after, wreathed in smiles. "I don't have bad days, just good days," he announced, thus proving that he is well endowed with the unbelievable arrogance proper to surgeons, "but this wasn't a good day, this was a Better Day." Now I don't think he would necessarily have announced to me that he'd done a bad job if that had been the case, but he's a pretty understated kind of guy, and he wouldn't have rushed in to crow at me unless there was good reason for it.
I haven't avoided blogging, then, because I'm disappointed in the outcome, just because those five days - surgery and the hospital stay - are not days in my life that I'm anxious to dwell on, let alone re-live. But what do you expect, this was major surgery.
I was in very serious pain a lot of the time, in spite of the self-directed morphine pump. At first, I could hardly move. I didn't have a bath or wash my hair all that time, which meant that my hair felt as though someone had dipped it in glue.
If anyone here ever has this surgery, just know that you've signed up for one - hopefully only one - very bad day. That would be not the day of surgery, since the anesthetic takes a while to wear off (I did have a general it turns out, their idea, I guess I misunderstood). That would be the first day afterwards. They want you to get up and walk that day, too, with a walker. I could just barely make it to the door of the room, and I thought I was going to faint.
There are just a few memories I want to keep.
- the look on the surgeon's face when they took me into the OR. There were three giant electronic consoles with lights and colors, looking like the command deck of the Starship Enterprise - more on this later - and next to them was Smith, grinning from ear to ear like a pig in mud. I saw that there was nothing on earth he'd rather have been doing that morning than this surgery. I like a man who enjoys his job. What a positive message, too, just before they knock you out. I don't think he did it for my benefit, by the way, I don't think he's even aware of it. This kind of enthusiasm, you can't fake it.
- everyone who came to visit. My husband, steady and true. My clients, who brought the tulips. (This is clearly above and beyond the call.) My oldest son. My foster-son the doctor, who sailed in masterfully and reviewed the chart. So much emotional support.
- my roommate. Semi-private room, curtained, and the poor woman was really sick, much sicker than I was, but she had the zip to take care of me, harass the staff on my behalf when I couldn't muster the energy, say the encouraging word. If you'd asked me ahead of time I'd have said I'd prefer a private room, but if the choice had been, a private room or a room with Katie, it's a room with Katie, hands down.
- Many - not all - of the staff members. Particularly the folks lower down on the staff level, below RN. There will be some stories on this in posts to come.
- Last but not least, getting the heck out of there. Hospitals, like a number of other institutions (the Catholic Church leaps to mind, but this problem is hardly rare) have lost track of their original purpose. In the hospital's case, this would be, helping people to get well. But the way they operate the place, a lot of time they're working in the other direction.
Tuesday, January 13, 2009
To see or not to see
I won't be given general anesthesia, apparently. Just a spinal. Of course everyone avoids general anesthesia whenever possible because of the risks.
So I asked the surgeon, "Just how awake will I be?" He said, "It's up to you. Some people want to watch; some don't."
My first reaction was, I don't want to watch and listen while someone cuts my leg off, put me out, but upon further reflection I've reconsidered. I'm sure it's fascinating, and if I were given enough of something so I didn't experience any anxiety it might be better to be present and to see. We are marvelously made, after all. And I'm sure the new knee is a marvel of a different sort.
Also, thinking about being present gives me the illusion of control.
It should make a great story to tell at parties too.
So I asked the surgeon, "Just how awake will I be?" He said, "It's up to you. Some people want to watch; some don't."
My first reaction was, I don't want to watch and listen while someone cuts my leg off, put me out, but upon further reflection I've reconsidered. I'm sure it's fascinating, and if I were given enough of something so I didn't experience any anxiety it might be better to be present and to see. We are marvelously made, after all. And I'm sure the new knee is a marvel of a different sort.
Also, thinking about being present gives me the illusion of control.
It should make a great story to tell at parties too.
Monday, January 12, 2009
Am I part of the problem?
See the following article in the Washington Post (you may have to "sign in" to view it, but it's free) http://www.washingtonpost.com/wp-dyn/content/article/2009/01/09/AR2009010902296.html?hpid%3Dopinionsbox1&sub=AR
This guy is arguing that health care costs in the United States as well as elsewhere will continue to rise because of medical advances. This is undoubtedly true, but I'm not sure it's a bad thing. (What spending should have a higher priority than health? War?) He doesn't directly address the differential among the industrialized countries on this matter, however. Why is it that Germans, for example, are getting very good health care for half of what we spend?
Click around. In a related article it is stated that knee replacements are 90% more common in the US (per capita) than in other industrialized nations. I have no idea whether this is true or not, and I'm not even sure it's a bad thing. This surgery is freely available in the UK, to my own certain knowledge, with no more "gatekeeping" than a few months' waiting period, so if the English and the Scots and the Welsh are not having knees replaced at as great a rate as Americans are I'm not sure why not. Maybe more people in the UK should avail themselves of this option.
At any rate, I'm not proposing to limp around for the common good. This guy also seems to think that this surgery is free to me, but I don't know what universe he's inhabiting. We have very good health insurance, and this surgery is still going to cost us plenty out of pocket.
But...what is money for? I'll economize somewhere else.
This guy is arguing that health care costs in the United States as well as elsewhere will continue to rise because of medical advances. This is undoubtedly true, but I'm not sure it's a bad thing. (What spending should have a higher priority than health? War?) He doesn't directly address the differential among the industrialized countries on this matter, however. Why is it that Germans, for example, are getting very good health care for half of what we spend?
Click around. In a related article it is stated that knee replacements are 90% more common in the US (per capita) than in other industrialized nations. I have no idea whether this is true or not, and I'm not even sure it's a bad thing. This surgery is freely available in the UK, to my own certain knowledge, with no more "gatekeeping" than a few months' waiting period, so if the English and the Scots and the Welsh are not having knees replaced at as great a rate as Americans are I'm not sure why not. Maybe more people in the UK should avail themselves of this option.
At any rate, I'm not proposing to limp around for the common good. This guy also seems to think that this surgery is free to me, but I don't know what universe he's inhabiting. We have very good health insurance, and this surgery is still going to cost us plenty out of pocket.
But...what is money for? I'll economize somewhere else.
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