Chapter 35: the surgery

 Chapter 35: The surgery

Before long the anethesiologist arrives. He tells me that Dr. P just arrived, and so they are going to get ready to wheel me back. He asks me the standard anesthesia questions. No I’ve never had a reaction to anesthesia, and there are no reactions in my family. He gives me the initial doses of medications to get me ready for sleep. I ask him if he can do a spinal anesthetic so that I can watch the surgery. He tells me that that is something they unfortunately do not provide. They wheel me closer to the operating room. The surgeon, Dr. P arrives, introduces herself, and tells me the plan of placing an intramedullary rod in the tibia. There’s nothing to do for the fibula. Once it’s aligned it will heal on its own. I ask her if she would rather have my fracture or a knee injury, and tell her I think I would prefer this. She agrees. She tells me she skis as well and that the fracture is faster to recover from and has fewer problems in the long term. I’m grateful for this information. The team and I start to get to know each other, they ask where I am a medical student and what career I’m thinking. I tell them the University of Washington and that I am hoping to do internal medicine. Of course Dr. P suggests orthopedic surgery and my anesthesiologist, anesthesiology. I laugh and say “we’ll see.” I then turn to the anesthesiologist, “What are the ABCs of anesthesiology?” I ask, He begins to answer (correctly) with Airway, Breathing, Circulation. I tell him no, it’s “Armchair, book, crossword.” He finds this exceedingly funny and tells me “I can understand that.” But don’t worry, I won’t need any of those during your surgery. They start to roll me back to the OR. I voice that I am worried the anesthetic may not be enough because I still feel rather awake. The anesthesiologist tells me everyone feels that way, and then gives me a little more. Then we get into the OR and I’m becoming very loopy. For some reason my phone is still in my pocket so I start filming a little bit, and then ask Dr. P if maybe we could do both legs as a preventative measure. She laughs and tells me that’s not something that’s done. Eventually they tell me they’re going to get started and I get the final doses of anesthetic. I turn off and put away my phone prior. I still wish that I could watch. When I wake up I’m in a hospital room, there are bandages around my right leg (only), and there is an intense throbbing pain in my right leg. I move up the blanket and try wiggling my toes—they all move. Then I sit up and feel for pulses in the right foot. Strong pulses. It doesn’t seem like there’s any neurologic or vascular injury. Fantastic, because that would be the worst case scenario for a skiing future. The nurse comes by and asks if I need anything and how I feel. I tell her about the pain, and that I otherwise feel OK. She does a quick neurologic exam and exams the surgerized leg approvingly, then hands me a urinal. She leaves and tells me she is getting pain medications. I take a moment to pee in the urinal (which I do in the bed). It’s an incredibly convenient system. I pee into the little jug, close it, and then put it at the side of the bed for the nurse to collect and poor out. I feel like I should get a collection of these urinals for long drives. The nurse comes back and gives me some Tylenol and oxycodone. I ask her if ibuprofen is not allowed. She says yes. This is pretty typical. There was some older research that suggested that non-steroidal anti inflammatory medications like Aleve or Ibuprofen slowed or interfered with bone healing. It was unfortunate because these were also the most effective medications for this type of pain. I looked through the research a little bit, and personally it did not seem robust enough to suggest that pain treatment plan. The risks of opioid addiction after orthopedic surgery seemed much greater and much more dangerous. Eventually Dr. P came by. She told me that the surgery went really well. She told me that I would probably be in the hospital for a few days, until I got cleared by physical therapy, who would help me learn to walk with crutches safely. I asked Dr. P about using ibuprofen. She said no because she was still worried about bone healing, but also bleeding, especially internal with the surgery. The bleeding made more sense to me. I said OK and would continue to accept the oxycodone and Tylenol.

Next, K comes by to see me. She asks how it went and I tell her that I think it went very well, and showed her how I could already move my leg, foot, and toes. The only place I was missing sensation was at the side of the knee, most likely due to cutting superficial nerves near the skin to place the intermedullary nail. K asks if I need anything from the place I’m staying. I hand her my keys and ask if she can bring my laptop and backpack with study stuff, as well as some of my sleep clothing, and then some new clothes and phone charger. She says she can do that. She takes my keys and I tell her the address of the place UW put me up. Amazingly, she leaves and in no short time returns with all of the requested items, and then tells me she turned off the thermostat just to make sure. I thank her profusely. I’m shocked, this would have been the perfect time to rob me. When K is back she tells me she’s really relieved we got Dr. P as the surgeon, since I seemed like a really serious skier. Then she asked when I would be out. I told he I didn’t know, maybe about a week or so? She said that sounded typical. With all of my comfort nearby now. I sent the attending neurologist I was working with a message about everything that happened, and that I wouldn’t make it to clinic that following morning. He told me that it was no problem whatsoever, asked me if I had any cool neurological findings. I told him I didn’t think so. He said he would round on me that morning, and that we could examine some new MRIs and go over them if I was up for it.

              Shortly afterwards. Physical therapy came by with some crutches and we practiced moving from the bed to a chair. It was surprisingly straightforward and not very difficult. I had been better skiing on one leg with my left leg anyway, so maybe that helped. We finished up and I moved back to my bed. THe nurse came by one more time and I told her I was planning to go to sleep soon and asked for some melatonin. She came back with pain medications and melatonin, which I promptly took. Then she told me sternly that just because I had crutches now did not mean I could get up whenever I wanted, and asked me to always use the call button before trying to get out of bed or move. I told her OK. This time I actually followed directions. I would be told this several times again at future hospital visits, when I would be a bad patient and go on my own to the bathroom or other parts of the room frequently. I imagine that at the University of Utah hospitals there’s a flag next to my name alerting nurses that I don’t do well following directions.

              I sleep fairly well without significant pain. I imagine that there must still be some of the anesthetic in my body, making sleep come more easily. I awake to the nurse and Dr. P looking over me and doing a quick examination. I probably slept 9-10 hours. There is a tray with breakfast and some coffee (bad, weak hospital coffee unfortunately). The bring the tray closer to me. The nurse offers me some pain medications. I take them so that I don’t “fall behind” with pain treatment, because I’ve felt it throb before and it was incredibly uncomfortable. I ask Dr. P when I’ll be able to leave. She says that I’ll be trying to walk with physical therapy today and tomorrow, and if that goes well I can discharge the following day. She tells me that while I’m technically 50% weight bearing on the right leg, that I cannot drive. I nod. They finish their examination and then leave the room. My attending neurologist texts me and tells me he’ll be up soon. He asks if I need anything. I ask him if he can get me an actually strong coffee. A couple minutes later he arrives with two large starbucks coffees. One is for him, one is mine, it’s a shot-in-the-dark. Espresso added to drip coffee. Maximum bitterness and caffeine. I ask him if I can pay him back but he refuses. He asks how I broke my leg and everything. I told him about the race and he tells me that was really stupid. I laugh and agree with him. I then tell him about K and the change of surgeon. He tells me that is really good because he had heard much better things about Dr. P, as he worked in the same hospital. “All things considered, I got really lucky.” I say, he agrees, and then asks if he can do a quick neuro exam. I tell him yes. Obviously the left leg is completely normal. He notes the loss of sensation in the right knee and tells me it’s most like superficial nerves. Moving down to the foot he notes a loss of sensation in the space between my first and second toe, as well as a little weakness with right big toe extension. When he tells me I tell him that it sounds like a partial deep peroneal (old name for fibular) nerve injury. He agrees with me. He tells me that there is a rare chance it improves with time. Looking at the initial x-rays, he believes that the injury is from the initial break, not the surgery. Then he tells me I’m a great learning case and that he wishes he had another medical student who could come see me. I thank him for his time and for his coffee. And tell him I’ll let him know when I’m getting out, and that I’m ready to come back to clinic as soon as I’m back. I don’t want to have to make up any rotation days.  When he leaves I take out my laptop and neurology books and begin to study a little bit. I had been ahead on studying so I don’t feel pressured. The neurology written exam would be in about a week, and so I was already mostly ready; I just wanted to review a few finer points and old material. Luckily however, the clinical portion of the rotation with its MRI reading prepared me very well for the exam on its own. As though the attending neurologist knew what I was doing, he came back into the room a few minutes later, looked at me as I studied, and then asked “are you allowed to move? Do you want to go look at some MRIs?” I told him that I just need to let the nurse know first, but that I would love to look at some MRIs. I tell him maybe he should stay in the room a little bit as an alibi. I call the nurse. When she enters I tell her my plan to go look at MRIs with the Neurologist. She says that’s fine as long as he walks me there and back and if I feel safe. With that I grab the crutches, swing over to the side of the bed, and we get on our way to the local reading room on the hospital floor that I’m on. It’s a fairly short walk.kWe began looking at an MRI for a women who had come in the previous night. She apparently had had initial visual symptoms of flashing and blooming lights, then experienced shaking of her arms and legs before passing out. Now she was awake and had overall poor memory of what occurred. The MRI is essentially normal. The neurologist suspects a migraine, apparently she has a history of migraines with slightly similar symptoms. He thought the lack of anatomical anomaly, history of migraines, and description of original visual symptoms made migraines much more likely, but he would get a continuous EEG just to be sure. I was surprised. This was the first time that I had heard migraines could be capable of so many seizure-like symptoms. Next MRI we looked at was from a recent stroke. It looked as though most of the left side of the brain was affected. The neurologist showed me the different imaging types, going through what they could show or signify, and which ones would show changes first. And how you could use this information to briefly approximate the stroke timing. Apparently this patient was not a candidate for lytic therapy (meaning breaking up the blood clot in the brain artery) because the stroke was too old, and the risk of internal head bleeding too high. He asked me what symptoms this patient would likely have. I told him aphasia (difficulty/ inability to speak and sometimes understand language), right sided paralysis and loss of feeling. All correct. I briefly thought about how terrible it must be to get a stroke, to have all the function suddenly taken away, needing to learn to live again in a new way, especially after so many years. It some ways a stroke seemed like a kind of death. Your old life, as you remember it, was over. And now you essentially need to learn to live as a whole different person, one who is unable to do many of the things we use to connect with the world. In retrospect, I sometimes feel lucky. One of the major causes of my initial symptoms of left sided blindness could be a stroke, and this would mean I would be likely to have another. Although my stroke risk is quite high now that I’ve had my brain irradiated twice. I feel lucky because even though I received an expiration date, I have not had to endure terrible loss of function. I am able to write, to walk, to cook and to hike, to enjoy new movies and new TV, and hopefully this winter, to ski. Sure my vision is worse, but at this point it’s only about as bad as it was during last ski season. General principles still apply, don’t ski near other people, especially beginners and children, ski trees instead—they don’t move.

              The neurologist walks me back to my room. Shortly after the Dr. P comes by. I ask her when I can leave, she tells me, “probably tomorrow, after a little more time with physical therapy.” I ask when I can start taking ibuprofen, and she tells me to wait at least two weeks (I would end up not following this advice). I ask her about driving and she says, “probably not a good idea,” especially if you’re still taking opioids. I can understand this. But I have different plans—the usual medically literate bad patient. I tell her about my knee numbness and suspected partial deep peroneal nerve injury. She examines me and aggrees that there is a nerve injury. She then tells me that it may get better with time, but shouldn’t cause any long term problems. I thank her, she leaves. Physical therapy comes in next. Today we do stairs. I fly through it. They give me the protective walking boot today. This makes it a little easier because I’m 50% weight bearing. I’m able to get around only slightly slower than when I didn’t have a broken leg. I asked the physical therapist about driving as well, telling him what Dr. P said. He told me that he was on my side, that if he were in my shoes he would probably just drive and not take opioids, except at bedtime. He suggested usijng both feet, right on the gas left on the breaks, and that with 50% weight bearing I should have no problems, but that maybe I should take a break every so often to elevate my leg to alleviate the swelling. I thank him, he goes off and the day finishes. The next morning the neurologist is the first to see me in the morning. He says, “I hear you’re getting out today.” I tell him, “I hope so.” Then he tells me that there is no rush to get back to clinic, and that he understands if I need a little time. I tell him that’s not necessary and that I’ll be there. I definitely don’t want to have to make up some of the rotation. Apparently the days I’ve missed so far are compatible with the acceptable number of sick days one can take off. Dr. P comes in next and tells me that she heard I did great with physical therapy the previous day. She tells me I’m being discharged and prescribes me some oxycodone and Tylenol, and lets me know that I have a follow-up appointment at the UW ortho clinic in a couple of weeks. I thank her, get my stuff, then text K, because I don’t know who else could help, who drives me home. Some other friends that I had met skiing who were just visiting temporarily had driven my car back to my home, for which I was very grateful. The PA who initially saw me up on the ski slope had my skis and poles, he reached out and asked me when was a good time that he could come by and drop them off. I tell him pretty much any evening;. He says he’ll bring them the next day. I get home and limp in with my crutches. Stuff inside I remake my room a bit and prepare for the next day.

              The next day I wake up early, make some breakfast, take some Tylenol and ibuprofen for my leg, it still throbs a bit. Then I drive to clinic. The neurologist is shocked but impressed that I showed up. He tells me that I didn’t need to come in; I tell him that I wanted to, and that I didn’t want to have to do any make-up. He understands. Today, of all days, I was going to interview and do a physical exam on a patient myself while the neurologist watched. This was one of the required assessments for the rotation. I took an opioid for pain, now that I wouldn’t have to drive for a while. Then I went to see the patient. After a thorough interview and physical exam I told her and the neurologist that I thought she had an essential tremor and should be started on propranolol. The neurologist agreed, then talked to the patient (likely to reassure her that he was involved; no one wants to think that they got all of their care from a medical student). We send her off with a prescription and follow-up in two weeks. Back in the office the neurologist tells me that I did a good job and that I did all of the physical exam components in a logical order and with correct technique. The neuro exam was always my favorite: it seemed the most useful, and was often the most diagnostic of the physical exam techniques. There are two more days left of the rotation. We finish up the day. I take some more Tylenol and Ibuprofen, then drive home. I practice walking with only one crutch and occasionally without any crutches—which does not go very well. The last day the neurologist has a summary of everything we’d gone through, and then we go through the woman’s EEG that we say the MRI of at the hospital. NO evidence of seizure activity. The neurologist tells me that I’ve done a good job and should consider neurology as a career. I thank him for all of his help, especially with looking at MRIs and EEGs. Then it’s time to head out. I needed to start driving to Seattle in order to take the written portion of the exam. I pack up my room, and the next day fill up my car, take a decent amount of ibuprofen and Tylenol, which helps much better than the oxycodone, and then, with the advice of the physical therapist, begin the long drive to Seattle. It’s going well. Sometime after I pass Spokane I stop at a coffee shop/ gas station. I get coffee and some food and get my foot elevated. It’s swollen and quickly feels better once elevated. With my food I take more ibuprofen and Tylenol. I’m not sure that I believe the research with NSAIDs that it slows bone healing, but the ibuprofen didn’t make me sleepy and seemed to be much more effective than the opioids. Eventually I get to the sublet that I had arranged in Capitol Hill, Seattle. I get in and drop off my stuff. I eat osome food I picked up along the way and the quickly review the neuro material for the exam tomorrow, and then go to bed.

              The next day I wake up early. I get some breakfast and drink a bunch of coffee, then take some ibuprofen and Tylenol, and then a little oxycodone because I am going to take the bus to the test. I get to the testing area. They ask me if I need any accommodations. I ask if I could have an extra chair to elevate my foot. Then the test happens. Somehow, even with opioids in my system I fly through the test without issue. Somehow it feels like the easiest test of medical school yet. After the test I get home. I’ve got two days before I need to start my next rotation. So I see if anyone is available to hang out for board games or some other activity until the next rotation starts. I get some bites. Soon my emergency medicine rotation starts. This should be interesting with crutches. Nevertheless I take the break beforehand to relax and try to recover as much as I can. It’s 4^th year of medical school, when grades are not so important, and so I do not study up before the Emergency Medicine rotation in any way. As A, one of my best medical school friends who was one year ahead of me, had said, “take as much time for yourself in 4^th year as you can.” 4^th year was apparently the last time you wouldn’t be incredibly busy all the time. I took her advice.

The rotation was cut short by the COVID-19 pandemic and students were pulled from their patient-facing rotations. Instead we had several online modules. At which point I had moved to more permanent housing for the remainder of the year. It was near Seattle Children’s hospital, which, having no pediatric rotations, was not the most helpful. But the best part of the living situation was the large yard and garden plot. I took my free time to plant an entire garden, which survived fairly OK—but it was my first time and I certainly made many mistakes. I also built benches for an outdoor patio area, which turned out much better than I had expected.