At my initial post op check up, I asked my surgeon if some mild swelling in my left ankle and foot as well as some slight darkening in color were normal. He said yes but never looked at them. I took him at his word and went home. I continued to feel better as the week progressed and was on track to head back to work on Friday evening, still on crutches and in my lovely brace of course. The pain was continuing to subside and I was only taking ibuprofen for pain control and Valium at night as needed. I was honestly just feeling pretty stir crazy and was looking forward to getting back into my groove. As the week progressed, however, I noticed that my leg started to turn darker in color. It was so gradual, however, that it didn't really strike me until I was getting ready for work on Friday evening that there may be a problem. I was dressing and noticed that the discoloration was from the hip down, and was dusky to ruddy purple from the knee down. There was some marked swelling and it was hard to bend my toes. Additionally, my leg felt cold to the touch. As a nurse, I know what signs and symptoms to look for after surgery in patients as a common complication is a DVT or deep vein thrombosis (a blood clot), however, I was missing several key markers for it. I figured it was just swelling from the hip and went on to work. The next evening, however, it was much worse, and the capillary refill (how fast the blood refills an area of skin when you push down firmly on it making it blanch) was slower than it should be. I took a picture of it and sent it to my mom. She freaked out a little. Kristin had returned from being out of town that evening and as I headed out the door I asked her if she wouldn't mind running it by her husband Brook, who is a surgeon, just to make sure it wasn't a big deal.
Sunday: I expected the usual DVT workup: EKG to rule out pulmonary embolism, ultrasound of the veins in the leg to look for DVT and blood thinners if indeed I did have a DVT. What I didn't expect was that after determining that I did not have a DVT and the PA was ready to discharge me, the ER physician came in, took one look at my leg and combined with the fact that they couldn't find any pulses in the foot or ankle by touch but rather had to use a machine called a Doppler, ordered a test called an ankle brachial index which tests for blockage in your arteries in your arms and legs. (I might mention that the test on my left leg made me nearly lose it the pressure of the BP cuff on my leg was so incredibly excruciating) Mine came back significantly decreased on my left leg. This of course set off a series of tests to then determine what was blocked, all with relatively potentially scary outcomes. First they did a CT scan looking for blockages mainly in the pelvis. When that was negative, they then did an ultrasound of the arteries in my leg looking for an arterial occlusion. Let me clarify for a moment here. DVT's are a fairly common complication after a surgery that keeps a patient bedridden in the sense that some 600,000+ a year are diagnosed. And those are the ones we know of. These are blood clots that form in a vein, which takes blood from an extremity back to the heart and lungs to pick up fresh oxygen. Arteries carry blood that just came from the heart and lungs and is delivering it to the extremity. What makes an arterial occlusion so much scarier than a DVT is that a blocked artery means that wherever the circulation is being cutoff at isn't receiving oxygen. That means that every minute all of the tissue beneath that occlusion goes without oxygen, it slowly dies. Arterial occlusions in the extremities have up to a 25% loss of limb rate. Scary! Very fortunately, that test also came back negative. Finally, they redid the ABI test using a computer that gives a much more accurate reading than the bedside one they did in the ER. It came back slightly lower in both legs than they would have expected but still passable and okay. After 9 hours, they had no answers as to why my leg was swelling, turning dark purple and freezing cold, and loosing pulses. As if that wasn't frustrating enough, at no point did we so much as see a vascular surgeon nor did anyone from my orthopaedic surgeon's large group ever come in. I know the ER did call vascular surgery in on my case because Kristin specifically told them to and she herself called the answering service for my surgeon multiple times and wanted him paged to the ER. I wouldn't have minded if whoever was on call for the ortho practice came in, but to be put through nearly every vascular test in the book and not so much as be seen by neither an orthopaedic surgeon from your surgeon's group nor a vascular surgeon I think is wrong. Clinical observation is an important part of medicine. Otherwise, we could turn medicine entirely over to computers and robots. The way I see it is if we went off tests alone, I wouldn't have had my gallbladder out 4 years ago. I had problems with it for 5 years before they finally took it out, despite the tests being normal. The first words out of my surgeon's mouth were, "I didn't need a pathology report to tell me that should have come out years ago." You have to put the tests together with the hands on assessment.
Monday morning: I had an already scheduled appointment with my ortho surgeon. I'm going to put a disclaimer in here and say that maybe someone made the group decaf coffee or something that morning. It was quite a strange appointment. Kristin had wanted to go with me to ensure that they were on top of things after the previous day's events, however, she had a previous commitment. So I left the house under strict instructions not to leave the doctor's office until they could thoroughly explain what was going on. They had already been copied on the ER visit because the PA took me back and made some offhand comment about me having quite the day yesterday. Another woman came in the room and said she was the NP and that we had met before. I said we hadn't met before but it was nice to meet her. She said she had assisted in my surgery. Okay hello, um I think it's a little obvious then that I wouldn't have met you since I was under general anesthesia at the time...so she looks at my leg and basically ho hums it off that it doesn't look very bad (unfortunately it wasn't looking nearly as bad for whatever reason that morning) and starts talking down to me about how 'we as medical professionals sometimes know too much about things and overly read into things and can panic ourselves'. Okay stop. Last time I checked I wanted to wait until my appointment that morning to have my leg looked at. I was being told by my coworkers, friends and, oh yeah, friend's husband who has been a surgeon for 20 years that it needed to be looked at. And so I called your answering service. Explained what it looked like to your PA. Who then berated me for not getting it looked at sooner and said I should have gone to the ER Friday night. So no I didn't push the panic button. When I start to get a little snippy with her, she finally goes out and gets my doctor. Wait. I just spent 9 hours in the ER last night and I wasn't going to get any face time with my doctor? He comes in, looks at my leg and says that they see this complication in about 2% of cases, what they call 'slowed venous return', explaining that there's swelling in the hip from the surgery putting pressure on the veins so they aren't able to return the blood to the heart as quickly as normal. He said that swelling in the hip peaks at 7-10 days (I was at 11 days post op). He said to wear a compression stocking which should help with the swelling and discoloration. He then said we needed to get physical therapy going ASAP. I had to remind him that he said we weren't starting PT until I was 4 weeks post op. I then also had to ask if he was going to have my stitches removed. He sent in the PA to do that. The PA then tried to schedule me for a 1 month follow up in July. And I had to ask about if PT would contact me in two weeks and if I could literally just start walking in two weeks or if I had to graduate down from the crutches. Truly a bizarre visit.
Wednesday morning: Brook was coming in to town and we were planning on him having a look at my leg as he has had experience in vascular surgery. But he did need to know some basic instructions that, come to think of it, were never issued from the orthopaedic office such as how many hours a day to wear the compression stocking, how long to expect to wear the stocking, at what point would they expect a resolution to the issue, at what point or what symptoms would warrant a call to vascular, etc. You would have thought they would have made those clear. After several phone calls back and forth, they basically said they didn't want to issue any instructions, they wanted vascular to made those determinations. Woah, wait. You never said you wanted me to follow up with vascular. If you wanted that, you should have said that at 8:20am on Monday morning when I was in your office. Now it's Wednesday, I have to get on a flight this weekend and go home for the following week, and there's no way they'll get me in by Friday. Not to mention now I don't really feel comfortable not being seen by vascular for two weeks if you want them to see me. So they then say that since the tests came back fine in the ER and vascular has no appointments this week, I'll be fine until I get back in town. Oh and by the way, you're at an increased risk for DVT's since you're flying. Thank God that girl was on the phone with me when she said that...my leg is turning purple,
Wednesday afternoon: Dr. Brook Redd to the rescue. Seriously. There is nothing like cutting through a mile sized ball of insane medical red tape than using a blowtorch. This is how healthcare in America should be. Parking it on a couch for five minutes, seeing what's what and making some professional judgement calls. And that's all there was to it. The tests were all normal so it was simply a matter of first making sure that clinically the tests weren't missing something based on the way my leg looked, and secondly how to manage it. That's the not so awesome part as it tends to involve a very sexy thigh-high compression sock
Saturday: AGONY. Okay I've pretty much been in agony since about 9:30pm last night. We went to a movie and while Kristin will be the first in line to tell you it's impossible to get me to park it I obviously did sit for the movie. Sitting is not the most comfortable position just yet. I was in a lot of pain by the time they dropped me off at home last night. Somehow, my Valium ended up downstairs instead of up--in case you're contemplating any kind of surgery involving crutches, either buy a ranch or temporarily move into one--and literally by the time I was in bed, settled with an ice pack on my hip and had realized it wasn't on my nightstand, I was in too much pain to move, let alone go all the way back downstairs to try and find it. I had a hair appointment Saturday morning so that I wouldn't have to mess with my hair on Sunday and Monday--I have strong leg muscles but there's no way I'm standing on one leg to straighten my hair for an hour. I suppose at this point it may be necessary in explanation to mention that on Sunday, after we got home from the ER, my mom called me and told me that my father passed away, which is why I am flying home. Obviously, one would not normally undertake that kind of trip two weeks post hip surgery with this complication as well. I took my aspirin and 800 mg ibuprofen (I'll take my chances with gastritis at this point) and headed out. Had the car washed and toughed it out through the hair appointment. I offered to come help Kristin with unpacking boxes as they just moved but thank goodness she didn't need any help because I literally sat in the garage for 10 minutes trying to find the willpower to get myself out of the car. I knew I was in trouble. I somehow managed to get parked on the couch with three pillows each under my leg and foot and ice packs on my hip and calf but they didn't get me far. As I had to work later that evening, Valium was off the table. I finally caved and took some Oxycodone when the spasms started. I tried to nap a little so that I wouldn't be too exhausted for work but the pain was still very significant. In nursing we have patients rate their pain on a 0-10 scale 0 being no pain and 10 being the worst pain of their lives. I was trying to convince myself I was comfortable enough to nap around a 5-6. Needless to say the meds were doing more for my brain trying to tell me I was okay than the actual pain. I'm just hoping the pressurized plane isn't a recipe for misery tomorrow. I vaguely remember texting Kristin asking about it and I think Brook called me. But between trying to not sound like I was crying--when you're hurting that much you're like a leaky faucet--and being a little med goofy it's all kind of fuzzy.
Perhaps it goes without saying that this whole week has quite possibly been the most convoluted week of my life. I don't think Hollywood could even have come up with this one if they tried. The Serenity Prayer may very well become my mantra for the next few days...if nothing else to keep myself from playing a game of real world kitchen style operation on my leg ha ha!
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