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

Theses: Piper (12) & Martin Luther (95)

In 1517 Martin Luther posted his 95 theses as a protest to the religious practices of the day. I had a similar occasion occur when I felt I was ready to be released from rehab following hip surgery. After 7 days in the hospital and 3 days in rehab, I tried to make as lucid an argument as I could for my release.

I posted these arguments, virtually, in my room. Had these arguments not worked, I was ready to take the next step of contacting the hospital ombudsman. But Dr. Govani, the doctor for the rehab wing, fully agreed with me, particularly on item #3, and I rolled past the frowning nurses on my way out.

Positive

1. I want to go home.

2. There is no medical reason for me to stay.
   
   
3. Medicare is the #1 entitlement cost. Let’s both do our part, today, to bring this cost down.

4. My wife needs to go home.

5. My home has all the necessary equipment for limited mobility.

6. I have had 4 previous orthopedic and 3 general surgeries, so I know the routine.

7. I have Visiting Nurses service.

8. I have done everything asked of me in PT and OT.

9. I have returned to medication levels prior to surgery, i.e., no stool softeners, no pain pills and no supplemental Lovanox.

10. Further stay has increased risks to me, namely:
    a. heart stress: BP went up to 157/77 last night just thinking about going home.
    b. cumulative risks from infections to myself and wife are getting significant
    c. my brain is starting to deteriorate
    d. my general overall mental outlook is declining

11. Dr. Nick Ting actually was ready to release me to home last Friday (11/26/10), but I declined.

12. I have met all my personal, post-surgical goals.

Contraindicated

1. Limited mobility. I have always improved in the past. I have a functional family (wife, son & daughter) for support

2. Swollen legs. This is improving daily now that I am getting out of bed.

3. Shorten stay. The ‘normal’ stay, while undefined, seems to be about 10 days. While I have been here only 4 days, I believe I am ready & capable of going home.

4. Temperature rise and incision bleeding. The temperature rise to 101 is a fluke (just my body getting ready to go home); the bleeding is minor and not unexpected.

I invite you to check out the history of my pre-surgery and post-surgery feelings by checking out our blog at:

http://cc-hip-redo.blogspot.com

Let’s aim for a 12/2/10 release, sometime around 13:00 hours.

Larry L. Piper

12/2/10, 01:30

(The bottom line is that I rolled out of the rehab ward about 15:00 hours on 12/2/10. The doctor said he had a flat tire, so that delayed his arrival about 1 hour. We got home about 20:30 hours with only two brief stops. I slept the last three hours of the trip, all of which was in the dark.)

A Christmas Letter

 We mailed the following letter (sans pictures) in with our Christmas card this year.

A reader of Dear Abby was making fun of the annual Christmas Letter. It went something like this: 'We spent the year traveling for world peace, our #1 son had an audience with the Pope and our #2 son won the Nobel Prize'. So with these caveats in mind, here goes our life in 2010.

We started the year by inviting two cats into our family, Mike and Ike. We had gotten rid of our last cat on 9/10/2001, so we took the events on the following day as an omen, and we had resisted adding anymore cats. The personalities of brothers Mike and Ike fit our family lifestyle, and we both get more from them than they get from us.

Larry took over the Presidency of the local computer club. It was not so much a position of honor or knowledge as it was to give the former president a break from his 14 year 'reign'. These presidential duties did temporarily sidetrack Larry from his main goal: to check into the possibility of a pacemaker. The story is long and convoluted, but essentially in mid-2009 Larry could tell he was NOT coming back from the back fusion surgery. His resting heart beat had dropped to 35, and a visit to the cardiologist confirmed that he was a candidate for a pacemaker. Unfortunately, the cardiologist 'forgot' about the office visit. But a new doctor had come to town. Officially she was an electrophysiologist, and she had a new $5 million operating room at her disposal. An appointment in March confirmed that a pacemaker was needed (bradycardia is the technical term), so on April 27 Larry had both a pacemaker installed and some cardiac ablation done. The two procedures were day surgery, and recovery was complete in two days except he could not raise his left arm for six weeks (to let the internal leads heal).

The big event of the year was our 50th anniversary. The manditory trip or family dinner was never on our radar. Judy concocted this plan to share our celebration with family and friends at the Loons baseball game. The Loons are a three year old, A-level professional baseball team in the Dodger's organization. So about 12 of our family and 18 of our friends were able to join us at a cookout at our house before we all enjoyed the game in prime seats behind home plate. Larry put together a PowerPoint show that contained over 100 photos from our married life.

The most visible accomplishments in 2010 were changes to our house. We did the changes with our checkbook rather than our own sweat, which was both a seismic shift in our philosophy and a boost to the local economy. The key was finding a good, local contractor. Mike first reroofed our 25 year old garage in May. When we saw what a great job he did, we turned him loose on new siding and windows for the house. Then we had a 55 year old spruce removed from the front lawn, and voila!, we had a new home. Checkbooks are a wonderful thing!

Larry had some adjustments made to his pacemaker and a second cardioversion done in late summer. Now his heart was hitting on all cylinders. But the hip pain had returned. The expert opinions said he should return to Cleveland Clinic for the redo operation after 22 years. Larry's original hip surgeon had retired in 2007, but a new surgeon even more capable than the first had taken over. The downside was a four month wait for an open surgical date. But then the gods smiled upon us and a date became available at Thanksgiving. The surgery took twice as long and the hospital stay was about three times as long as expected. The recovery period will be tougher than previous surgeries, but as Judy noted, 'if we had done the surgery at any place other than Cleveland Clinic, Larry might not have walked normally again.'

All in all it has been another good year. We have a lot to be thankful for. Life is good.

Pregnancy, Marathons and Orthopaedic Recoveries

Pregnancies, as we all know, take 9 months to reach fruition. And the process cannot be shortened to 1 month, as the joke goes, by putting 9 men and 1 woman or 9 women and 1 man on the job.

Running your first marathon takes a similar amount of time. I had a couple DNFs at the 26 mile distance before I devoted the necessary 9 months time and effort into training for the distance. I have talked with and coached other runners who have voiced similar feelings in conquering the marathon distance.

So that leads to an orthopedic surgery recovery. This is a subject on which I have abundant experience. The 'party line' on hip replacements is 1 year before you will be back to normal. My 1st hip took a little less than 9 months; the 2nd hip took a little longer. But the back fusion was a totally different matter. The bone paste used in the fusion takes a minimum of 3 to 6 months to 'set', and, like concrete, continues to harden up to 2 years later. During this first 3 to 6 months, one has fairly restrictive movements.

So this is the predicament in which I once again find myself. My left hip redo on Nov 23 will take 3 to 6 months to set because Dr. Muschler had to use bone paste to build up my hip area. During this time I must have absolutely zero weight on the left foot for 6 weeks. At this point we will make another trip to Cleveland Clinic where an X-ray will show the healing progress. I truly believe that Dr. Muschler will extend my non-weight-bearing restrictions another 6 weeks. This can be a depressing outlook. During the previous back surgery in Nov, 2008, I passed the time by writing a book about my life -- to give to my two children. What I will do this recovery period is unknown at this time. All I know for sure is that I have 9 months to do it. Any suggestions?

The photo above is from day 20. Tomorrow I expect the Steri-Strips to be completely removed (Day 22).


Larry