Pacemaker Issues

I added this addendum to this blog to complete the medical history of my hip surgery.

I uncovered the fact that my pacemaker was not returned to its original settings following my hip surgery at Cleveland Clinic. While the change might appear to be trivial, particularly for a 72  year old person, I found it to be life-changing the farther my recovery progressed. I suspect it was a major factor in my recovery process.

First a disclaimer. I find the medical field strongly adheres to the mantra "one size fits all.' Secondly, in the field of heart surgery, the person who does the surgery is not the contact person  for any followup, as it is in the orthopedic field.

The facts are: on Nov 23, 2010, just prior to my hip surgery at Cleveland Clinic, a device nurse turned off the breathing response to my pacemaker. The next day this response was turned  back on; the device nurse was Janet. (When I asked why this was necessary, the answer was they didn't want my heart to speed up for any reason during surgery.) On May 16, 2011, when I  met with a tech rep from Boston Scientific, along with my regular device nurse, Peggy, it was discovered that, while the breathing response factor was on, it had been set to 2 instead of the  original 4. Also the 'auto-lifestyle' setting was ON--which puts the pacemaker in the 'one-size-fits-all' mode. Finally, the reason for a shift in resting pulse from 60 to 70 was never satisifactorily  explained, but it may have something to do with another setting that kicks in when AF is detected. The first two of these changes were not detected by Peggy on her device check in April  20, 2011, nor the Tele-Trace check on April 25, 2011. The third change in resting pulse from 60 to 70 was actually changed by Peggy in her April 20 checkup. So we agreed to reset the  breathing response back up to 4 and turn off the auto-lifestyle. I wanted a higher response setting (the range is from 1 to 16), but we agreed to get together again in two weeks to evaluate  the results. A second response factor for heel strike was reduced from 11 to 8.

I keep a daily log/diary of both my vitals and exercise efforts. This log was telling me that my maximum HB was only 75 to 80 after a strenous mile swim, hence my call for help from Boston  Scientific. For the record thirty minutes after the May 16 changes, I swam my daily mile. My time was two minutes faster than normal and my maximum HB was 112. The next day the max HB  was at 126--which is tough to measure. So I knew the new settings were making a big difference. I had been seeing similar low maximum HB results when doing a Modified Bruce Protocol  on the treadmill; after the May 16 adjustments, I would max out my HB at 131, sometimes in as little as 4 minutes when doing the regular Bruce Protocol.

My original pacemaker settings DID NOT have the breathing response turned on. I got this corrected on August 5, 2010. Some discrete inquiries while at Cleveland Clinic brought comments that it is not unusual to not have the breathing response turned on, particularly for older people. Terrific!

The bottom line is that, looking back on how much I struggled those first few weeks following hip surgery to merely walk around, I must conclude that my heart's inability to speed up with  increased effort on my part was a significant factor in my recovery progress. This lack of breathing response was, of course, limiting my efforts to maximize my cardio-pulmonary output in the pool or on  the treadmill.

If you are reading this blog and wish further details, I can be reached at larryp56@chartermi.net.I would remind the reader that I have written detailed accounts of all my surgeries, so I have voluminous records.

Larry Piper

12 Weeks - Good To Go

We made the 12 week checkup trip back to Cleveland Clinic on Monday, Feb 7. Our son, Scot, once again did the driving for us, only this time we took his pickup. That was a testament to how well healed I was -- more bouncing around than a car ride. 


The results were fabulous. He said I could do pretty much everything, although it will take a few weeks until I regain enough strength and flexibility. Specifically, he said I could increase the weight bearing on my surgical leg from 40# to 90#, over a two week period. This would involve continuing to walk with my crutches and/or 4-posted walker. Then I could switch to a cane until my 'limp was resolved'. I have opted to continue on my twice weekly therapy at the Midland Community Center -- one day in the pool and one day with land therapy. The principle of the pool therapy is to walk in water that is more and more shallow until I can put my full body weight on the surgery leg.

Dr. Muschler (whose picture is below) said I did not need to return until the one year anniversary of my surgery -- thereby skipping the six month checkup.  


This trip to and from Cleveland Clinic was completed in just over 12 hours, definitely a PR, and one that likely can never be broken. Although we waited in X-ray for almost an hour, we got right in to see Muschler. When he saw the X-ray, Muschler was convinced all was well. We had to wait about 15 minutes for Bridgette to type up the therapy order. It has been apparent to me that the staff personnel in A41 orthopedic area are much more disorganized than the place was 22 years ago when I saw Drs. Borden and Brems. 


In a related matter I met Cheryl, who is the PA for Dr. Krems. Krems took over all of Borden's patients. That raises the question: How did I draw Muschler?


We completed the day with the Piper ritual reserved for celebrations of the highest importance, namely, indulging in a marshmallow shake. 

Technically, this visit was only 11 weeks; Muschler was going to be gone next week, and he agreed to move me up (rather than back) one week. Also, my original surgery date was Feb 1, so Muschler moving me up by 3 months now looks like a real medical windfall.

This likely will be my last entry into this blog.

Larry
 

Keep Up The Good Work

With those words Dr. Muschler concluded our 30 minute, 6 week checkup.

He was completely satisfied with the 5 X-rays that showed my hip was both healing correctly and that the surgery had left my hip-pelvis area in perfect alignment. The ability of orthopedic surgeons to read X-rays is uncanny; they see things like a psychic reading a palm or crystal ball. If anything, they are too good at interpreting X-rays; I will give you an example. Trudy, the X-ray technician apologized for the painful contortions I had to endure in order to get the exact angle that Dr. Muschler wanted to see. I replied, "... no problem. I know that X-rays are the reason I drove 300 miles for this checkup." Then I added, doctors are so hung up on measuring my progress by reading my X-rays that I could walk into the examining room with 3 heads and the doctor would hardly notice."


If I were to list the highlights of the day, they could be viewed as all negative: getting up at 5:30 am in order to make the 5 hour drive, the struggle and pain of negotiating the stairs to get out of our back porch, the long wait and sitting on a hard wheelchair in both X-ray and to see Dr. Muschler, a few obnoxious people with their cell phones, being very tired at the end of a 14.5 hour day and finally taking a fall at the last rest stop on the way home. But most of these things are either routine with most doctor visits or could have occurred had I been closer to home.


So, as the proverbial question goes, what did the doctor say? (I love this comment because most people don't remember much of what is said nor do they ask the proper questions.) But, to give an answer, what I can do is continue for another 6 weeks with the restrictions of weight bearing on the left foot, do all my PT exercises plus the addition of some back stretching, no further restrictions on sitting time, and no restrictions on sleeping on either side or my stomach. The biggie was his approval of my request to start water therapy. What I cannot do is drive the car (although I got a temporay handicap sticker), restricted abduction movements of the surgery leg, and restricted straight-leg lifts of the surgery leg. Also, he doesn't want me to use weights on any of my dozen existing PT exercises (something I have been fudging on). 

Items that were of no concern to Dr. Muscher were just those items that hospital and visiting nurses dwell most upon: swelling in the surgical area, swelling in the legs and ankles, vital signs, bowel movements, even pain levels. 


So the 'choke collar' has been loosened a notch. Judy and I were extremely happy as we left the Cleveland Clinic at 15:30 hours, just in time to beat most of the afternoon traffic jams. I signed a paper that should have a digital copy of the X-rays sent to me in a few days. Once I get these X-arys, I will include them in a future blog.

 The best story of the day was when Dr. Muschler finished his detailed analysis of my X-rays, with emphasis on how happy he was with the healing process and the perfect alignment of all the parts. I then commented that I would assume that some surgeries did not result in such good results. His answer was a classic: "Not with my patients."

I should have more to report tomorrow because my first day of the second 6 week recovery period was a big day.


Larry

Uh-Oh

Robert Fulghum's, the All I Really Need To Know I Learned in Kindergarten guy, 3rd book was titled Uh-Oh. He gave the term a variety of possible meanings. His underlying message, however, was that Uh-Oh was more than a momentary reaction to a small problem, but more an attitude on the universe.

With that background perspective, I had two such Uh-Oh moments in my hip recovery odyssey. The first occurred on or before Dec 23. Judy noticed I had a large, swollen area around my scar. Neither of us had noticed it before, but agreed it was more prominent when viewed or photographed from the front/back rather than the side (which is the normal view). Neither of the two visiting nurses had noticed anything different in their visits a couple days earlier, but again they were seeing me more from the side.

I immediately jumped to the conclusion that a dislocation had occurred. Dislocations are the #1 warning from orthopaedic personnel, although I personnally place it behind infections and pneumonia when considering surgery risks. I have seen it up close and personal in my right shoulder three times. I could not sit as comfortably as previously, but I was not in any great pain. I cut way back on the PT and used ice to minimize the swelling.

Of course the big question was what to do. The calendar almost guaranteed that few medical personnel were available, either in Midland or Cleveland. My conclusion was that venturing forth from my house was a bigger risk than doing nothing with whatever had occurred to my hip. (That is the reason that nursing homes and hospitals DO NOT evacuate on hurricane warnings because any evacuation process inevitably kills one or more patients.) I also discovered that my three levels of phone contacts at the Cleveland Clinice were: (1) gone on vacation, (2) not a working number and (3) a wrong number.

So by Monday, Dec 27, I went with my first line of defense: the visiting nurses. Although they were not scheduled to visit me that week, my case worker Ashley was available. I was into the mindset that an X-ray would be needed to give a definitive answer to the dislocation question. I had previously determined that my local doctor was working, but that his X-ray technicial was off for the week. That meant I was facing a long wait at either the local emergency room or its alternative Urgent Care. Also, I would be exposed to the travel/fall risks and the interaction with a bunch of 'sick people.'

When Ashley arrived at 10 am, I immediately 'mooned' her. Her reaction was less than medical. She proclaimed my hip as 'funky', but did agree an X-ray was in order. Her phone call to my doctor got me an appointment at 15:30 (no X-ray could be scheduled without a doctor's visit first). I had by then, after numerous false starts, reached a live body at Cleveland Clinic. Their recommendations were: (1) drive the 5 hours to visit the Cleveland Clinic emergency room and (2) X-rays could NOT be electronically transmitted.

The doctor visit was a positive experience on many levels. I was able to negotiate the steps in my house to get to our car. I was happy to breath fresh air and see something besides the inside of my living room. The actual doctor visit was a totally positive experience. He did feel the hip was NOT dislocated. I had a fluid pocket that goes by various names. He suggested some things to do and not do, all of which made sense to me. (My doctor had recently had a hip operation of his own, so he had first hand experience with the procedure.) We had a pleasant exchange on other issues, something that had not occurred in recent office visits. Of course what Cleveland Clinic thinks of my hip and the long term consequences will have to wait until Jan 3.

The second Uh-Oh also occurred about the same time as the hip swelling issue. The bottom line is that I broke the LCD screen in my #1 laptop computer. The details are convoluted, but it was basically the result of my inability to sit up and use the laptop in a normal position.

This Acer laptop had all my recent medical musings written in the form of a diary. I was in good shape for backups, but the thought of all the other programs (over a hundred) that might or might not be restorable was too much to fathom. I did manage to use the laptop with an auxilliary screen, but that mode of operation soon degenerated into a non-functional computer. The local repair guy said replacing Acer LCD screens is not financially viable. He also suggested that, based upon some of the crash messages, the hard drive might have gone south.

But I was successful in both removing the hard drive and reading data from it. I expanded my computer skills another notch in accomplishing these two events. I still face the prospect of buying a new laptop, but as they say, that is only money. More daunting is the prospect of installing the laptop hard drive into a fresh computer, and thereby eliminating the pain of recovery. Bill Gates says I cannot do it; that move implies I am trying to 'steal' one of his precious operating systems.

One of Fulghum's interpretations of an Uh-Oh moment is that a few years from now it won't make any difference. Stay tuned for that outcome.

Larry