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!


  1. Hey Josh, though I don't know you personally I know your name from the New England running scene. Good luck with everything in the upcoming weeks post surgery. I'm dealing with the same injury (2/22 was my last decent run, a few 6-8 mile runs the next week and nothing in the last 4 weeks) and it's looking as if surgery is on the near horizon. When you have a free minute, would you let me know if you recommend anything specific in the build up to surgery? I've read it's important to get the quads and hamstrings as strong as possible beforehand. I'm not sure if strength is the answer or trying to gain some flexibility. Anyways, just looking forward to your thoughts/opinions. Thanks.

  2. Mic Med. I'm happy to offer you any advice/support you want. Just email me at katzman.josh@gmail.com.

  3. Wow, great read Josh! I can't believe you ended up with Deep Vein Thrombosis! That is freaky as hell! You've had quite a year, and your realism tinged optimism is inspiring. Best of luck with recovery...and it sounds like you've been reading Buddha's Brain already!

  4. What an ordeal. Thanks for sharing this intimate experience, Josh. There's lots to be learned from what you've been through, but especially your attitude to it all. Stay strong, bud. On the technical side, is that a common complication from surgery, or just horrible luck?

    1. Oh yeah, this is Eric A. My old blogspot id was eazyebeneezer. Long story ;-)

  5. I just figured the name was a reference to a Phish song or something! As for the technical side of things, yeah, clots are a known complication of surgery. In my case though, it sort of comes down to bad luck.