Monday, April 21, 2014

Losing The Zen, Finding Relief

The doctor had just called and you could hear the concern in his voice.  Nearly three weeks post-op and the fact that I had developed chills with a low-grade fever and no other symptoms did not bode well.  The knee was hot to the touch and the swelling, despite being wrapped with ice and compression nearly 24/7 the past two weeks, had not changed at all.

I put the phone down, sitting on the edge of the Ottoman, about to lift myself with the two crutches that have become the key to my mobility the last three weeks.  Liz had refused to go to bed until we knew what was going to happen.  As I braced myself for the throbbing pain that I now expect when raising myself from a seated position, I stopped.  I didn't want to hurt.  I didn't want to suffer.  My fingers went to my eyes, which were beginning to burn with warm saline.  My nose got stuffy, and I sobbed.  I shook my head, thumb and pointer finger holding the inside corner of each eye, tears flowing, angry that I had "elected" to have this surgery. "There's no use thinking about that now," Liz counseled.  The TV showed highlights from the day's game at Fenway, at that moment focusing on the pre-game with the survivors from the marathon bombing in 2013.  I was too self-obsessed, too far into the realm of self-pity, anger, and frustration, that I couldn't feel compassion.  My suffering was all that mattered.  What if I did not come back from this trip to the ER?  What if I had a raging infection in my leg, and the only solution was amputation?  What had I done? I sat there, Liz consoling me, hand on my shoulder. In our seventeen years together I have broken down like this maybe three times.  "I'm sorry," I sobbed, my thoughts now turning to what she and the boys would have to go through without me.  The memories that would never be made, the missed joy and experiences simply overwhelmed my psyche, which swirled with negativity and hopelessness.  I was engulfed in an imagined future that was horrible.  There was no other way to say it: I was scared.

Nearly everything about this post-surgical recovery has gone so horribly wrong.  With another trip to the ER in front of me, I expected this time to be no different.  With Liz's encouraging words, I gained some composure and loaded myself into the car.  The only positive thought I had?  Maybe I'll get to see that damned mountain lion that is hanging out around here.  It was 11:17 PM, Sunday night, two-weeks and one day, almost to the minute, since my last visit to the ER for complications from this knee surgery.  A surgery, which should have been "simple," but has proven to be anything but.

One benefit of of becoming a "frequent flier" at the ER is that I know how to make my stay a bit easier.  I brought a backpack filled with my meds, and other "essential" items, that I could throw my jacket into.  I went knowing there was a real chance I would be spending a huge amount of time there.  I went armed with knowledge about what tests to ask for and what I wanted to avoid.  Despite these mental and physical preparations, I was not ready to hear the doctor telling me, given how the knee looked and felt, there was a good chance that another surgery to "clean out" a (very likely) infection was probably in the cards.  The last thing I wanted was to have these wounds opened up again, and someone else poke around my knee.  I just wanted my ability to walk back. I was tired of suffering.  It was 1:30 in the morning - I was also just flat out tired.  "If this is infected, and we don't treat it, you will probably never run again because it will do some serious damage to your knee." I try not to swear much in public, but, in this moment, "Shit," was all my vernacular could muster.

Growing up in Vermont, I remember "tapping" a sugar maple tree on our property and then my mom boiling down the clear sap to a dark, amber, deliciousness.  Lying in the ER bed at Winchester Hospital at 4:17 AM on Marathon Monday, this was most definitely not the image in my mind's eye as the doctor took the largest needle I'd ever seen and prepared to "tap" my knee to pull as much fluid as he could out of it.  This fluid would determine the course of my immediate future - if it tested positive for nasty bugs, I didn't want to think what would happen.  If it didn't, well, I'd likely have some relief from the pain/pressure I'd been feeling near constantly for the past two weeks.  Finger's crossed as the needle broke the skin.

My late Grandpa Barney would have said, "That's a crap-house load of fluid." The doctor said, "Well, it's not a record, but that's certainly a lot of fluid." After pulling many, many ounces of what looked like blood (and not puss), I caught a small glimmer of optimism.  "The tests will take a couple of hours, and the real result will be the culture, which will take a couple of days, but we'll start you on some IV antibiotics, and I'll let you know as soon as I get any word." With that, the doctor left the room, and I settled into a fitful couple of hours, with one thing abundantly clear: draining all that blood had relieved a lot of pressure and discomfort.  I could flex my foot without the knee feeling like it was going to explode or pop.  Still, since I've been taking anti-coagulants for blood clots (the first post-op complication), the concern was more bleeding in the joint and blood simply refilling it.  As my father (a family doctor up in Vermont) has told me through this process, "Blood where it is not supposed to be, especially in/around a joint, can be extremely uncomfortable." I had experienced that the last two weeks.  It was 4:31 AM.

I spent the next hour and a half falling in and out of sleep, trying not to move my knee, thinking, for some reason, that this would limit the bleeding, and relishing the lack of pain/discomfort in the joint, even when just lying there.  I tried to meditate, to find my Zen, but fatigue and the fervent hope that no "nasties" would be found in the blood, made it difficult to settle the mind and just embrace the moment and reality.

"I know it's been a long night, but I have good news.  The first tests are showing that this was just blood so you won't be needing surgery right now.  Your INR (a measure of the level of anticoagulant Warfarin in your blood) is also therapeutic now, so, if you follow up with your PCP this morning, you may be able to stop injecting yourself with the Lovenox (a "bridge" medication that prevents blood clots from getting worse.  You inject this medication into your belly, every twelve hours.  I really don't enjoy it, and have a whole new respect for those that have to do things like this their whole lives.  I had been looking forward to stopping this routine since my first trip to the ER, 15 days before).  We'll know for sure in a couple of days with the culture, but, for now, I'm going to give you some antibiotics, and send you home." It was 6:02 AM.

The fact that a second surgery would not be needed lightened my heart.  The fact that my knee had felt fine since being drained (and remaining propped up) made me excited to "test it" as I left the hospital.  I envisioned being crutch free, triumphantly walking into my house unaided and pain free, celebrating a massive victory in what has been the slow progression back to health.  I put my foot down on the floor and stood up, hope replacing the fatigue I felt.

I nearly fell back down.  I could feel the blood returning to the knee, and, as my dad said, "it felt a rather uncomfortable." It took me a couple of minutes to stand upright on my crutches.  My head swam in a hazy cloud of an all nighter and pain.  By the time I got to the car, I was winded, teeth barred against the discomfort.  It hurt.  It took me four minutes to get the ten feet from the car to the house because of the throbbing.  But then I sat down, propped the knee up and the pain went away.  I've spent the next 13 hours sitting on the couch, watching the incredible performances at the Boston Marathon, and, unlike every other day for the last fifteen days, my knee has not bothered me one bit while sitting.  I've been flexing my foot with a smile on my face because it feels "normal" to do so - not like a water ballon being squeezed by a tantrumming toddler.  Sure, it hurts like hell when I get up, but just thinking about the fact that I will likely get a comfortable night's rest, has been exhilarating.  Knowing I have (at least a temporary) reprieve from additional surgeries is huge.

We had a picnic dinner in the living room tonight so that I could keep my leg propped.  Cooper and Jacoby were willing to play games with me lying on the couch (before Liz took them to the Marathon, Jacoby and I were trying to play a game and I kept falling asleep as he asked me the questions - "Dad?  DAD!  It's your turn!" His sweet little voice kept waking me up when I would fall asleep ever thirty seconds or so).  I eventually gave in and mumbled that he could just play on the iPad.  Cooper (who when he first saw me in the ER following last-year's Vermont 100, told me, "You could have just walked it in."), kept telling me, "I can't wait until your surgery is better," or "At least the plica is gone and can never bother you again." I couldn't agree with him more.

I wasn't proud of myself for losing my Zen last night before heading to the ER.  But, just like "tapping" the knee led to some serious relief, by allowing myself to fully experience all those negative thoughts and emotions, even if it was just for a relatively brief time, I was able to find some sort of relief from this silly ordeal that has consumed my body and mind since April 2.  A good initial lab report didn't hurt any either!

Tuesday, April 8, 2014

Time Heals All Wounds: A Story In Two Parts

Part 1: Sometimes You Need a Really Sharp Knife

On Monday, March 31, 2014, Dr. Anthony Schena received a call from a patient (let’s call this patient, oh, I don’t know, Josh).  A message was left that went something like this: “Doc, I know my surgery to remove the plica is on Wednesday, but, I’m not kidding, just two days after we finalized the date for this, the knee started to feel better, and, well, I don’t know.  I’ve been able to run to and from school this past week, and am just wondering what your thoughts are about this, if the surgery is really necessary.”  What I (I mean “Josh”) couldn’t articulate in the message was the feeling that, like my recent procurement of a new winter running jacket, having surgery at this point, after fourteen weeks of discomfort that had seemingly, miraculously healed itself (literally, two days after finalizing the date), was, somehow a “luxury.”  The pain was (mostly) gone, so why did I even need this?  Afterall, I was running again.  Each day that past week, I had made it to school and most of the way home.  Why would I willingly let Dr. Schena cut into my knee and put me back on the DL for several more weeks?  I couldn’t help but shake that feeling of being the impatient American, a consumer, looking for the “quick” fix that would cure my personal woes.  Because there was no pain when running, I started to think of this as “cosmetic surgery.” I started to think about the miles lost during recovery.  If the operation had just been scheduled for two weeks before, before I had been given the gift of pain-free running again, there would have been no question what the right choice would have been - cut this plica out!  It’s amazing how quickly we can ignore history when our present situation fits our mental model of what we hope will happen.

On Tuesday, April 1, 2014, Dr. Anthony Schena left a message for his patient Josh.  It went something like this, “Josh, you can always postpone surgery.  However, I think, as you’ve experienced and know, this is something that has already come back three times.  You may feel fine for a day or a month or a year, but then, one day it will bug you and you’ll be out again.  You’ve been out for almost four months already.  If you want to postpone, just call my office.  Otherwise, I’ll see you tomorrow.”  This was the reality: the plica wasn’t going anywhere, and it would become irritated again.  At some point down the road, I knew I would be facing this same choice again.  

Over the past year (perhaps starting at the Vermont 100), I’ve begun listening to both my “gut” and other’s advice more careful, more thoughtfully, especially those most important to me.  And so it was that I found myself on the morning Wednesday, April 2, 2014, shaving my leg before heading to the hospital (I was looking forward to the shaving of the leg part, because, really, when else would I have such a great excuse to do that?).  It was certainly not an easy decision (the surgery, not the shaving).  Of course Googling “plica surgery recovery” did not help make up my mind, as I soon discovered that the Internet is full of horror stories of people that, years later, still have pain.  A doctor was about to stick some rather invasive tools into/through my knee!  But I am learning.  I tried to not heed the words of anonymous users like DJBlueSKY1179 on random Internet forums and instead focus on the voices of people that know me.  After a couple of weeks of counsel from friends and family, it was the words of my father (a family doctor in Vermont who had happily taken my MRI to all of his orthopedic and radiologist friends, who had all graciously looked over it for me) and my wife (who was the one who was going to have to deal with all the post-op kvetching on my part) that truly helped me make up my mind.  First, my father and the several experts he had shown my MRI to had all seen the plica.  They reported that everything else in the knee looked great and that (in the universe of the knee), the plica was not near anything “of consequence” to the structure of the joint.  Then there were Liz’s words.  She has been patient with me these months, and truly understands how much of my personal identity is wrapped up in my ability to run long distances (not necessarily compete, but to be able to move, under my own power, where I choose.  She also has the distinct pleasure of knowing me well before I was a runner!).  She reminded me that another two to three weeks of recovery would pale in comparison to how frustrated and angry I would be at myself if I postponed the surgery, when the plica became irritated again.  I would have to start the whole process over.  It had taken fourteen and half weeks this time.  She was absolutely right.  Ultimately, this decision was mine to make, and, heeding the inner-voice, I knew I’d be going under the knife.  Time does heel all wounds, but, I realized, sometimes those wounds need to be made by a really sharp knife in an operating room.  

Just over 72 hours post-op, the procedure seems to have gone quite well, with the doctor telling us that my knee, “Looked perfect, and now the plica is gone.”  Liz and I actually got to have a little “date” pre-op, where we simply chatted for about two hours, interrupted only occasionally for IV lines and status updates (I also took great pride in setting the alarms off on the pulse-monitors, because my heart rate was reading 39 BPM.  After having run only about ten miles a week (if that) over the past fourteen weeks, I was sure my resting heart rate would have been much higher.  If nothing else, this objective measure made me think, “I’ve still got it,” which was a great boost of optimism before knowing I would be very limited in activity for a good chunk of time post-op).  When I removed the surgical dressing forty-eight hours after getting home, there was much less swelling than I had imagined.  The stitches certainly tug, my calf is a bit tight, and I am being super conservative in putting weight on the knee, but I’ve even felt improvements today - a more “natural” stride with the crutches and more confidence in placing weight on the leg.  Patience has become the name of this new game, and it is a patience tinged with an optimism I did not feel much over the last fourteen weeks: if I am cautious now, the bloody thing that bothered me is no longer there, so I’ll be okay!

This has been my biggest lesson so-far: be optimistic.  The days leading up to the surgery, I still couldn’t help but Google “plica surgery recovery”  (I’m still learning not to trust the myriad opinions/voices on the Interwebs - I’m not totally there yet!).  A fascinating article about Joan Benoit Samuelson (from Runner’s World) appeared in the search results.  Turns out she had the same procedure I did back in 1984.  “A few days later, she tested it to the . . . tune of 17 miles.” 17-days post-op, she won the first ever women’s Olympic Marathon Trials.  She then went on to win the first-ever women’s Olympic Marathon!  Her story certainly has given me a reason to be optimistic (and wise about recovery.  The article also explains how, following her “test-run” she had caused such damage to her leg muscles that she needed 14-hours a day of “microcurrent stimulation.” Sorry, I’ll pass on that).  Although I feel “weak” (mentally and physically) because I succombed to the knife, I am determined to enjoy the recovery and subsequent return to form.   Right now, when I am overly-conscious of every movement my knee makes, this process feels glacial, but, by the time summer arrives here in New England, and I am running pain free, it will be but a distant memory.  And, for years to come, each time I come home from a long run, the kind when you’re out so early that you experience that subtle transition from dark night, to gray dawn, to bright day, the kind where you’re so thirsty and tired, and it’s so hot you wanted to stop miles before, I will smile and likely not even remember that time, one April, when I was laid up on the couch for a couple weeks.

Part 2: In Which I Am Grateful For Having Written Part 1 Three Hours Earlier

“Patience has become the name of this new game, and it is a patience tinged with an optimism I did not feel much over the last fourteen week: if I am cautious now, the bloody thing that bothered me is no longer there, so I’ll be okay!”

Somewhere, in the deepest folds of my brain’s gray matter, those words, which I had finished writing just hours earlier must have been playing on infinite repeat, because the only thing that was really freaking me out was the fact that the nurse had just casually mentioned that I would have to self-inject the medication before he casually left the room.  And now, about twenty minutes later the doctor and nurse were back explaining that I would be starting Lovenox immediately and the nurse would be “teaching” me how to inject it into my belly every twelve hours.  And now, just seconds after that conversation, the nurse was grabbing a fold of skin and fat around my belly, saying, “This is going to burn and itch for a bit” and stabbing a needle into my gut.  It was 2:30 in the morning.  What in the hell just happened to me?

Shortly after finishing Part 1 of this story (which was supposed to be the only part!), I went up to bed.  It was Saturday night, about 10:30 or 11:00.  My calf (below the operated on knee) had been really sore since Friday morning, when I first tried to take some “substantial” steps (I mentioned it as “being a little tight” in Part 1.  That was like an ultrarunner saying they feel “fine” at mile 80 or so.  It really means things are not well).  It felt like it does after a really steep/long run.  I figured it was the stress of surgery and the fact that I had been trying to not move the leg much post-op.  It remained sore for much of the day, but I thought little of it, trying to stretch a little, even massage it.  Nothing seemed to help, but I thought little of it.  Saturday morning dawned and, getting out of bed, the calf hurt.  It hurt enough that I got a little nauseous and thought, “This isn’t right.  It shouldn’t hurt this much after a night of rest.” I laid back down and focused on my breathing, trying to push the “what if” thoughts out of my head.  The calf continue to bother me throughout the day, especially after it had been lying on pillows.  That really didn’t seem to be right.  When I got in bed this night  (again, minutes after finishing Part 1), the calf hurt simply resting on a pillow.  This is definitely not right, I thought to myself.  I lay awake for most of an hour, thinking that something was terribly wrong and that Liz would discover the worse in the morning.  It was about 11:30 PM when I got up and called the surgeon.  On the other end of the phone I heard the exact advice that, since Friday morning, I had been desperately trying to deny in my mind, “Go to the ER and be prepared for a long night.” I woke Liz up and refused to let her drive me, simply telling her I would hopefully be home by the time she woke up.

And so there I was, lying in a hospital bed, having an ultrasound of my left leg.  Perhaps it was a combination of fatigue or having already accepted that this is what was going on, but I was not too shocked or surprised to hear the ultrasound tech say, multiple times, “There’s a clot.  There’s a clot.  Here’s one.  Let’s just check here too.” I had had a feeling that this is what was happening, and just stared at the monitor.  The tech brought me back to the room - I tried to be gracious to her for a doing such a thorough job -  and I closed my eyes, and started meditating, focusing on my breath, letting thoughts roll in and out of my mind.  It served me well by helping to avoid the fears and anxieties that were starting to surface, from the question of what this meant for my running, for my post-op recovery, and, more importantly, for my family - was my telling Liz I would be home by the time she woke up a simple act of denial? - and ultimately the question of my mortality - could this kill me?  The short answer to that last question was, yes, especially if I had simply been my typical stubborn self and thought myself invincible.  The good news was that as soon as the nurse stuck that first needle into my belly, I was on the way to protecting against this worst case scenario.

The official diagnosis is Deep Venous Thrombosis (DVT), which is a fancy way of saying that there are a bunch of blood clots in my leg that shouldn’t be there.  These are possibly complications from surgery, especially of the knee and hip, and, if left untreated, can ultimately lead to a pulmonary embolism (PE), when a clot “breaks loose,” travels through the heart and into the lungs.  A PE is not good: an estimated 100,000 Americans die of PEs every year.  Perhaps it was denial, perhaps it was that I had already accepted the reality of this situation, but this was not one of the two things that really freaked me out.  Those were, first, fact that I was going to have to start injecting myself with “blood thinners” (which are actually anticoagulants, which limit the blood’s ability to clot.  A very good thing if you have congestive heart failure or DVT or PE.  A not so great thing if you are, say, running on a trail and trip and get a really deep cut (which I have done more than once)).  And second, that I would be on some type of anticoagulation medication for three to six months.  These two facts of my newly shaped reality really freaked me out - like sick to my stomach, dry mouth freaked me out (beyond the fact that these steps which I fear will likely prevent me from developing PE, another positive is they have helped me realize I will never become an IV drug user.  I’ve been able to do the injections, but there is no way to get around it except to say they are absolutely horrible.  I have a whole new level of respect and empathy for what diabetics must go through on a daily basis).  

Since that first shot at 2:30 Sunday morning, there has been one moment where I felt nearly completely overwhelmed and simply thought to myself, “FUCK.” It was Sunday night, right before I went to bed.  I was checking on my boys, who sleep in a bunk bed.  I looked at them and thought, “What the hell was I thinking?” I questioned, again, if the surgery was even necessary and felt like a horribly selfish person for doing something simply to be able to return to running faster.  It was a sad moment for me, where I thought about all the “what ifs”; and especially what this could have meant for my family.  And then, as I hobbled over to kiss both of the boys, the crutches clanking so so much I feared I’d wake them, I thought of a lot of the lessons I’ve tried to teach to my students this year: about acceptance, perseverance, kindness and strength of character, and the negative thoughts were fought back.  The reality of the situation, of the present, returned, and I stopped thinking of a past that I wanted to reinvent (not have surgery), or a future that I feared (all those what-ifs), or the “perfect” future I craved (a speedy post-op recovery).

As I got in bed that night, I focused on my breath again and just let my thoughts flow freely, not judging them, but observing them.  In the end, this new reality has not changed the lesson I learned when I thought the recovery was going to be “quick.”  It is still about patience, still tinged with optimism, albeit a bit different than before.  This optimism is less about my own ability to return quickly to running great distances, and is about something much bigger to me: an optimism for the good of humanity.  While my physical recovery will be longer, my mental and spiritual recovery has begun in earnest.  I feel so much gratitude for all the people (especially my family and friends) that have been so supportive and caring, listening to my bellyaching (literally - it’s from those injections!).  A gratitude for the surgeon, ER staff, ultrasound tech, and other medical professionals (especially old Dr. Dad Katzman, who has provided several hours worth of consultation already), who have helped me make sense of this situation and get me on the path to recovery.  It has brought a deeper gratitude at hearing the tales of friends who are running trails and winning races - something that, at times, had brought jealousy, but now just creates a sense of awe at what the human spirit is capable of (and offers some incredible incentive to heal quickly!).  It has even brought a deeper gratitude for my students, who, when I returned to school (a couple of days later than originally planned) for the first time today, treated me with a kindness and care that is not often demonstrated by teenagers.  I was so impressed with their concern and compassion that I joked with my fellow teachers that I was considering faking more surgeries in the future and showing up on crutches more often.  As for actual surgeries . . . I’ll avoid those as long as I possibly can!