Finally! Back on the bike!

Its been since July 19. That was the last day I rode my bike, until today. July 21rst marked the day I had surgery to repair the damage I caused when I fell on May 5th. Until I woke up from the anesthetic, I was working off the idea that I would take about 3-4 weeks off my bike. It was the next day that I realized the surgery was much more involved than I (and even the surgeon) thought it would be. Rehab started two days after surgery, when I began to do quad sets and isometrics.

Reality still didn't really hit until I had to have the surgical drain placed. That was 2.5 weeks after the surgery. Then the infection that set my recovery back a few steps. And finally getting the drain removed. Once the drain came out, it was finally safe to get to the gym and ride the recumbent stationary bike. Then the upright. And I've been walking. And walking... and finally a little jogging (very little). But my knee felt good. A little tight, but that's going to be the case for a while.

Today, I got on my bike and actually RODE some of the rolling hills around Antelope. And my knee didn't hurt!

It was only 5 miles.

But I did it.

 Tomorrow will be the ride from my home to light rail. And back later in the day. :-)

Infection Control and an update on Jackson-Pratt

The antibiotic I am on is really making a big difference. Its knocking out the infection really well. My knee hasn't felt this good in a while. Mobility is much better, pain is down to almost nothng, swelling down, and redness is gone. My surgeon made an interesting comment when he was checking it last Friday, "Hey, its starting to look like a knee again!"  I've been 100% on the antibiotic. Even have an alarm that wakes me up at midnight to take it. Haven't missed a dose yet.

Last Friday, 5 days after I visited the E.R., my surgeon and I sat down to make a decision about the drain. It was at a point where we needed to decide if the drain was causing the fluid to continue, or if the drain needed to stay in longer because my knee needed more time to heal. But since it was already the cause of the infection, it would probably mean I would either be on antibiotics until it came out, or I would end up sick again.

So, the drain was removed. The surgeon started putting together everything he needed to pull the drain as well as to cover the hole left over and provide good compression. While he was doing that, I asked him if I could get a release to work EMS again. He asked me, "Will you be careful?", with a tone that was a little comical, but that implied he was serious and not joking. "Yes, I will be.", was my response. And I meant it. I don't want to go through this again, not that my work in EMS did this to me.

Remember how I mentioned the joy of it going in? Taking it out was without anesthetic. Not that I think the anesthetic would have worked, since infected tissue doesn't anesthetize very well. He takes a 4x4 and places it on my knee right where the drain came out of my skin. I mentioned to him that I accidently tugged on the drain line the day before, which gave me a taste of what this was going to feel like... ugh. But, I wanted it out like no tomorrow.

"Are you ready?", he asked. "As ready as I'll ever be..." Only took a minute, but yeah... it hurt. Sometimes they do, sometimes they don't when they are removed. Since it was infected already, the tissue was pretty tender. Yeah, I watched the whole thing. I also got to take a good look at the drain (the portion that stayed under the skin for over 2 weeks). It didn't have holes. It had rails, made of a flexible plastic, along the sides. The suction pulls the fluid into the rails, and it comes out the tubing. Really interesting, actually.

So, I ended up with a bulk dressing again. Lots of 4x4s over the hole left where the drain came out, and a bulky pad over that, wrapped up with a gauze wrap and and ace wrap over that. In this case, the "bulk" of the dressing is to provide pressure on my knee to discourage fluid from accumulating again. I took the rest of the day off of doing anything, and went home to be kind to my knee. With the drain out, the pain level dropped instantly. Still tender, but not painful except a few twinges once in a while. I did fax my work release over (Yes, he gave it to me) to the Rivercats, so I could work there again. I've really missed it a lot.

On the EMS front, Saturday, I worked a triathlon, then went to a football game and worked there. Saturday night, I worked a shift for another EMT at the ballpark. Sunday, I worked another triathlon. It was really hot both days. Yeah, I jumped in with both feet. But it felt really good to be hands-on with patients again, and I needed to get tired again doing some good physical work. My sleep hasn't been very good lately, due to the pain from the surgery, the drain, the infection, and more. I slept really well the last two nights. I know mentally I've missed the work. I didn't realize that I physically did as well.

Uh Oh...

For the last few days, I noticed an increase in the amount of fluid coming off my knee through the surgical drain. Obviously, it shouldn't increase, but decrease. Saturday evening, my knee was sore, but I thought it was from moving the scar tissue around, since I was walking more. I iced it, and it did feel a bit better. Went to bed...

Yesterday, my knee looked good in the morning. Still more sore than it had been, though. Even doing my quad exercises hurt more. Went to breakfast with my roommates, and to Walmart. Walking through the store, I noticed my knee seemed more swollen and painful. Finished there, and went home. Iced my knee right off the bat. It didn't improve the pain and swelling much though. And about an hour after, I started getting chills. I very unjustly blamed my roommates for my freezing, as the thermostat was at 67 degrees (They both said they didn't change it).

So, I pretty much took it easy the rest of the day, hunkering down in my bed under the covers. I did get up when my business partner Steve returned gear he used during an event, and I was pretty sweaty when we were offloading gear.

So, last night, I decided to ice my knee more directly that through the ace wrap. Took it off, and immediately realized it wasn't an overuse problem...

 

You can see the redness and swelling in this picture. Sorry the quality is so poor.

Uh oh... My knee was red, hot, and swollen, as well as being painful. I pressed on some of the area that seemed more swollen, and realized there was fluid in there, even with the drain in. I pressed on the skin, and 10cc of fluid came out within a minute. It was obviously an infection. I did ice it, which didn't do anything. Knee was still as hot after I iced it as before. Checked my temp, which was 100.3. Bleh. Rewrapped it, made

A trip to the ER was in store, which I did do. Sent a message to my surgeon also, so he knew what was going on. Ended up with I.V. antibiotics, and a 10-day supply of oral antibiotics. Got home about 12:45 this morning. Thankfully, they cut me loose rather than having me take up space in a bed in the hospital. Got home and promptly fell into a coma until my alarm went off reminding me to take my next dose of antibiotic. My knee is less painful and less swollen this morning, which is a good indicator that the bug causing this is sensitive to the antibiotic, a real good thing. I have a planned appointment with a P.A. in the orthopedics department this morning, which is now also an ER followup appointment.

A Week with Jackson-Pratt

OK, well, "A week with a surgical drain tube and suction device sticking out of my leg"... sure does sound less poetic than the title of this post, doesn't it?

As I reported in a previous post last Tuesday, I had the surgical drain implanted. Since then, it has been doing its job: keeping the fluid from building back up in the tissues. It has allowed the dermal layer (the layer under your skin) to lay down to the tissues underneath, and to begin the process of permantly adhering to those tissues. Literally overnight, the color of my skin around the suture line improved, showing that perfusion of the tissues was happening again. This is really good! Healing happens when blood supply is returned to tissues. Otherwise, it is very possible that a section of the skin might have not survived, or would have taken a very long time to heal. It has also had a nice secondary effect... the fluid that was building in my lower leg since the first surgery was also removed via gravity and suction. I kept my leg elevated most of the week to encourage it to drain. It was a little disconcerting when the amount of fluid removed increased, but it made sense.

My surgeon has kept close tabs on me during this last week. We have used a form of telemedicine to do this. Simply, I email him status updates daily, along with a link to pictures of my leg that I place on my domain. You can see these at http://www.portable-essentials.com/pics/knee if you wish. Warning: They aren't pretty. He then replies to my email, with any changes he wants me to make, or lets me know to continue doing what I am doing. And he answers any questions I have. I've been very impressed by his care and caring. Even this week, he is on vacation; however, he is continuing to read my email, and saw me this morning in clinic. He could have passed this off to someone else to deal with this week, but he didn't. For those of you who remember when my late husband Rory ruptured his patellar tendon, it was this doctor that was able to repair it so that Rory was able to continue to walk, until a few days before his death. He is very well respected, and I fully understand why.

On to this morning's appointment... things look good. Everything is healing, and the dermal layers are staying down. The drain is still putting out fluid, and although was briefly clotted off Saturday and Sunday, I was able to get it unclotted so it worked again. Took a bit of work, but it seems to be behaving again. With any luck, it might be out on Wednesday this week. This is a day-by-day thing, with no set date for it to be removed. This is just a plan at this point. Every day it is in, though, my risk of developing an infection is there. So the faster my body stops producing fluid around my knee, the better. If it comes out too soon, then fluid will build up again, and another drain will need to be placed. It wasn't fun the first time. I'd much rather not have to do that again. If I have to, of course I will, but lets hope I don't.

Knee pic

This is what my knee looks like with the Jackson-Pratt surgical drain in place:

And yes, it hurts.

Surgery Part Deux is over

The surgical drain is in. And I am back home. Drove there, and drove back on my own.

I got to my orthopedic surgeon's office this morning, and needed to wait a little while. Not a big deal, but it ratcheted up my apprehension level a bit. I *really did not* want to go through with this. I was hoping all night that the fluid would just disappear, but I knew it wasn't going to happen. When I woke up this morning, I knew I was going to end up with the drain. I just didn't want it. I can't imagine anyone that would.

The doctor came in, and we chatted for a few minutes while he checked out my knee. We talked about the blister that popped up Saturday under a steri-strip, as well as part of the suture line not looking real well. The skin just isn't perfusing (getting needed oxygen) very well, due to the fluid underneath not allowing the tissues to heal together and form those all-important new blood vessels. After our discussion, it was evident that the drain needed to be placed, if anything to allow the tissues to heal properly. He thinks I blew the internal sutures the first time I bent my knee. Not that I did anything wrong. The tissues just wouldn't hold the sutures. Fluid accumulation probably contributed to this as well. The problems I am having aren't uncommon for this surgery, but still disappointing.

There are a few types of drains used for wounds. And I had some questions before we got started:

1. What type of drain was he going to use?
2. What about antibiotics while the drain is in place?
3. What about culturing the fluid still in my leg?

The surgical drain is (as I was hoping) a Jackson-Pratt (JP) drain. This is a "closed" drain, with a bulb on the end to maintain suction on the area being drained. This type of drain is safer than "open" drains, which allow more opportunity for bacteria enter the wound. Here is a picture of a JP before it is placed where it is needed:

The end of the drain has a trocar (a large needle). You can see it in the picture above. They come in different sizes. I think a 7FR was used for mine. The white ends of the tubes are the end that stays in the wound where the fluid is. Only one tube is used for each drain. I only have one drain (thankfully).

!!! WARNING... THE REST OF THIS IS PRETTY GRAPHIC... WARNING !!!

The surgeon prepped my knee with sterilizing solution, a large area, well past where he was working. Situation normal... always go farther than you need. He then started numbing up my knee, starting above my kneecap. Used a fair amount of lidocaine. He then numbed the area below my knee where I have little feeling from the accident. Some fluid started coming out from the anesthetic needle hole below my kneecap. Gave the anesthetic a few minutes to take effect, tested to make sure it was numb...

...and then he took the trocar and went in from below my knee. Didn't hurt at first, but then he went through an area that wasn't numb. OUCH! Took less than a minute, but wow that hurt! He continued to thread it through the tissues. Then he went through the skin above my kneecap where he had numbed up initially. A little bit of positioning of the drain line with it pulled completely in through the entrance wound, and it was attached to the suction bulb. Yep! Fluid started coming out.

He extended the drain with more tubing to make my dealing with it easier. Yep... still working. Covered the entrance wound with tegaderm, covered the exit wound where the drain line comes out of my leg with xeroform (antibiotic/petroleum jelly gauze) and tegaderm (clear plastic dressing). The picture above shows it covered, with some fluid coming out. He covered the blister with some xeroform as well to get it to heal, the suture line with gauze, and then covered my leg with Kerlix (a type of fluffy gauze roll), and ace wraps over that.

We were talking while he was doing this, and joked about the patient table I was on (He really likes that table! But it has very little padding. Almost like sitting/laying on a backboard with a folded towel on it), and I learned more about this type of drain. I have to admit, it was pretty interesting to watch him put this in. I've taken drains out of people before, but never saw one put in. I would rather have seen it put in on someone else, but it was still interesting!

I need to empty the bulb periodically, and then squeeze it to maintain suction. No antibiotics right now. The fluid coming out looked just like it has all along. No signs of infection, except possibly the small area on the suture line and blister. That is managed with triple antibiotic ointment (like Neosporin). If I start showing signs of infection, then he will prescribe at that time. I am back on "house arrest" until my next appointment, early next week. With any luck, the drain will be removed them (if my leg isn't putting out more than a few drops of fluid at that point). I did refill my pain meds in case I need them. Got my leg elevated also. As I am typing this, the lidocaine is wearing off... we'll see how it is in a little while.

Surgery Part Deux is tomorrow

There wasn't supposed to be a part 2.

I should have been well on my way to getting back to normal. Movement-wise, I am doing well, but the fluid is still on my knee. Seems to have stabilized, but it is still there. So, barring a miracle of the fluid going away overnight, I will be back in a procedure room tomorrow, more than likely having a drain put in my leg.

I haven't done anything wrong. I've followed exactly what I was told. Yes, I have been a good patient. I stayed a couch potato for over a week, with one brief foray for food, and one movie (with my leg propped up at the theatre!). I didn't even lift any medical gear during that first week post-op.

Why is this happening? I don't know. But it has to end.

More info tomorrow.

Frustration

I wonder if I did the right thing at this point in having the surgery. After all of this, half of the fluid aspirated off yesterday is back today. I just can't believe this! I had the surgery to STOP this from happening, not to make it worse!

Surgery Update

OK. Sutures came out today. Well, it was actually one LONG suture. The P.A. that pulled it was duly impressed at how large the incision was, since most bursectomies (removal of bursa) are much smaller. The white steri-strips will fall off in the next few days. There are two areas that still need to heal in a little more, but it looks good, scar-wise.



He also noted the large amount of fluid that had accumulated. We agreed it needed aspiration (thank you!). So, he got all the stuff together, numbed up the location he was going to put the needle into (It is the same general area I used before as well, which is numb already), and went ahead and started aspirating the fluid off. This is OUTSIDE THE KNEE, everyone! He used a 30cc syringe, and pulled off one, two, three syringes full, plus another 22cc. Total 112cc removed! It was almost a record for him (115cc is his record). I had guessed yesterday that there was about 100cc, so I was close on my guess. Last Friday, when I emailed my surgeon, I told him more than 40cc, but more swelling has gone down, so the fluid was more evident. The fluid looked just like it should, no sign or smell of infection. Hopefully, the fluid wont come back, since that was why I went through this surgery in the first place. Bandaid placed over the aspiration site. The picture was taken after the sutures were out and the fluid pulled off. I am using a pad on the area where the fluid probably originated at, putting pressure on that area, to try and convince the area to not fill in again, and an ace wrap for compression.


I came home, and immediately iced my knee again. It was a bit sore from the suture removal and aspiration, so I figured it was a good idea.

 

(Comparison of my knees)

So, I am off the crutches (yes!), and am allowed to use a stationary cycle (yes! yes!), and exercise at the gym. No regular bike riding for at least 3 more weeks (sigh...). Once the skin heals a little more, I will be able to bend my knee more than 90 degrees, but not yet. I may need to wait up to 10 days. I can shower again, too! In terms of EMS work, I can supervise, and do some work, but no kneeling on that knee. So, I will stay a supervisor for a few more weeks. I really want patient contact again, and I miss my work at the ballpark, but need to let my body heal first.

Back to the grind

Well, this week, I started back to work, but from home. Worked Monday-Wednesday at home, with my leg elevated. Once the over throbbing went away, I began to keep it propped up, just not resting on the floor like normal. That worked well. Well enough, that I decided to try and work at my normal cubicle. Since there is a fair amount of walking involved to actually get to my desk, I drove to work, rather than taking light rail in as I normally do. Still using my crutches for distances, although at home I am walking around without them. I have my leg propped up on a box of all things! Tried propping it up on my desk, but it isn't very comfortable:

You can actually see my wrapped knee through the blue jeans. Might try some different things.In the meantime, my office chair broke. It had a crack in it when I acquired it over a year ago, and seems to have decided that now is the time to commit suicide. Bad timing. So now, I am scrounging to find another one. Budget woes are apparently hampering our ability to order needed things, such as something to sit on.

I have been feeling what I think is "suture pull" for the past few days. As tissue begins to heal, with sutures in place, the whole area feels like it is being tugged on. Hard to know for sure, since the feeling is not quite normal. Been doing the quad set exercises that apparently were supposed to have been included with my post-op instructions, but were not. I know them anyway, so its not a biggie for me. Even sitting at my desk I do them. I have noticed there appears to be fluid accumulation around my knee, right around the suture site, going up the medial side of my knee and over the kneecap. I sure hope it is just post-op, and not the seroma back again. I'd be "extremely disappointed" if this was all for nothing, except making it worse. So, I've been wrapping the ace wrap tighter than it was wrapped post-op, hoping to convince my body to absorb the fluid back. Hope it works...


Trying to see when I can ditch the crutches. I have to admit, when walking distances, it is more comfortable than walking without.

In the meantime, I am going back to EMS in a supervisory capacity for a few weeks. No kneeling for me for a while... got to be a compliant patient. Got several new EMTs, and I don't want them working without good supervision.

Post-op Day 6

Well, I spent yesterday as a couch potato again. I knew that going to the movie would extract a price, and it did. When I went to bed Saturday, I needed to take the vicodin for pain control, and keep my leg up (which I've been doing). But, I couldn't sleep. It just hurt. Ended up taking more meds 4 hours later. Finally got a couple hours sleep, then got up, went out to the couch, propped my leg up, and watched the TdF final stage (Distraction does wonders for pain control!). That was a great finish! Right after the end of the race, I dropped off to sleep on the couch.

I woke up some 3 hours later. Felt a lot better at that point.

Take-Home Message: A drugged sleep is no substitute for the real thing!

But I knew I needed to keep my leg up. So, most of the day, except for necessary moments, I stayed on the couch with my leg up. Had some swelling in my foot and ankle again (a minor post-op problem), so keeping it up was important. Around 6:00pm, I sat up, and started using the recliner function in my couch and pillows to keep my leg up, but to actually sit up, and not be lying down.

Today, I woke up after getting some sleep last night. Got back to work today, but working from home, since I need to keep my leg up still. Can't really do that well at my desk. Might try to get in to work later this week, but that is a *maybe* at this point. The plan is to work from home this week, and get back to my desk next week.

Been checking my wound, and I noticed bruising that was starting to resolve. Guess I didn't see it before. Still sore, but nowhere near as painful as it was last week. Looks good.

Yesterday and today, I've been walking around the house without my crutches, which is nice, but outside I am using the crutches. But I am feeling a lot more confident walking, and hope to ditch the crutches entirely by the end of this week or early next week (With the surgeon's permission, of course!). As I put in my previous post, I moved to the forearm crutches, which are vastly more comfortable than underarm crutches.

Cleo is still guarding me...

Can you see the look on her face???... "You will NOT move!"

I am not a patient patient, but I am trying to be...

Post-op Day 4

Took a good look at my knee today, and changed the dressings under the ace wraps. It doesn't look bad:

The yellow xeroform is where the suture line is. Pretty large incision. The blue lines are (I think) landmark lines that the surgeon used. My knee is still swollen, but looks good. No sign of infection (always a good thing!). No, my leg wasn't hanging down. It was propped up on the pillows, and I took an overhead picture.

Started doing some quad muscle tightening today. Not a lot, but a start.

I am on crutches, although I ditched the underarm crutches in favor of my old forearm crutches. My roommate dug them out of my garage for me. Since I am weight-bearing, why not? They are WAY MORE COMFORTABLE! Haven't used them in a long time (For a few weeks after I rolled my ankle in 1999, prior to that 1992-1993 when I was between ankle reconstructions, and after the 2nd one in 1993), but I am, at this point, very glad I didn't get rid of them. Every time I get up to walk, it is not comfortable (read: painful), but after several steps, it is ok (read: tolerable).

I finally got stir-crazy enough to need to go out and DO something. So, I decided to go see Harry Potter and the Half-Blood Prince. I've wanted to see it since it came out, and decided that my mental well-being needed to take a little priority. So, I made sure I had no narcotics in my system, grabbed a pillow for my leg, and drove to the local theatre to watch the movie. Went to the first showing, figuring that there would be less people there than any other time on a Saturday. Not really, but I managed to score a seat along the "disabled" seating that allowed me to prop up my leg on the seat next to it (That God for those new connected seats that the armrests swing up and away!). For the next 2 and 1/2 hours, I de-stressed. BTW, the movie is good!

Went directly home, and got my leg back UP. Stayed that way for a few hours. Went back out briefly to get some fresh veggies for dinner. Made a killer salad later, and had some mushroom ravioli (really yummy!). Good dinner.

Well, no deed goes unpunished. My increased activity has taken a bit of a toll. Pain is a good reminder. Ended up taking more vicodin for pain control. Something tells me I will spend all day tomorrow with my leg up.