Tuesday, June 23, 2009

Elbow injury - "terrible triad" - Ketamine experience

This is part 3 of 4 posts I have written about my elbow surgery. You can read them all here:
Part 1: The Emergency Room 

Part 2: Surgery and Recovery
Part 3: The Ketamine Experience

Part 4: Follow Up

In the Emergency Department
I was in the emergency department for a broken arm and dislocated elbow. I was given Propofol for conscious sedation. For some reason, I wasn't completely knocked out by the Propofol and the emergency room staff was not able to reset my elbow. After a couple failed attempts, they decided to give me Ketamine to completely knock me out so they could really yank on my arm. The experience was very intense, so I thought I would describe it.

The medical staff entered my area in the emergency room, a bed with curtains drawn around it. There were six or seven people in the area. It felt a little crowded.

They did a safety pause. They said who I was and what procedure they were going to do (an elbow reduction) and what side was going to be worked on. They began to give me the Ketamine and asked me how I was doing. I think I responded once before the Ketamine took effect.

My Ketamine experience

I was knocked out and had no idea what was happening. At a measured pace, I started realizing that normal things just simply were not real. I would think of something, like one of the houses I lived in and as I pictured it in mind, it simply dawned on me that it simply wasn't real. I knew the thing I was picturing simply did not exist, as if it were a figment of my imagination. It was rather matter of fact. Every time I thought of something concrete, in my drugged state, I would realize it was fake. It felt like reality was literally falling away from me. Soon connections between things were falling away. I would picture two locations and how to get from one place to another. Within seconds of thinking of it, it would fall away because I knew it simply was not real. Now, as I realized things were not real, I would forget they even existed.

I started picturing peoples faces, and they would fall away from reality. I pictured my physical body and that fell away. Nothing I knew was real. Life simply was not real. All I saw was a huge white plain with a grid and light. I had the sense of energy coming from the light and from the point where my non-physical being was. This is what was real and nothing else. Nothing mattered, nothing ever existed and nothing had meaning. I could not even remember anything from the real world. I had no concept of people, of places, of self or even time. None of that ever existed.

I began to observe my situation. My first thought was: if this is what it feels like to be schizophrenic, I now completely understand what that feels like. The second, scarier thought I had was: is this what death feels like? Did I die? Did something go wrong during the procedure? I felt fine and happy. I thought if this is death, it's not bad -- I was okay with it. I am not a religious person, but I can see how this could be a moving experience for a religious person.

Slowly, I started to come down. I started picturing things from my life again. I pictured houses I had lived in, people in my life, and for some reason maps and roads. Even though I could picture them, I didn't know if they were real. It was really confusing and a little bit scary. I remember picturing different things and thinking over and over: "I don't know what's real." I think I might have even been saying that out loud. This lasted for a little while.

I was becoming aware of more things. I could hear someone talking to me. It was the nurse. She asked me how I was doing and I think I responded "I don't know what's real anymore." I remember feeling or seeing my bad elbow above my face and thinking that's simply not real. I remember also repeatedly saying in a slow dragged out voice "wowwwwwww". I think the medical staff was getting a kick out of that. I think I remember someone giggling a little bit.

At this point, I think the staff went to get my girlfriend Kate. She later told me they seemed a little panicked, as if they wanted her in my area as soon as possible. She came in and talked to me. I opened my eyes and saw her and it was great. I was so happy to see her face and know she was real. I was slowly starting to feel grounded again. I was pretty sure Kate was real now, and I knew I was in a room surrounded by a curtain, but I had no idea what was outside of the curtain. I was talking to Kate and the nurse, but for some reason I couldn't really see the nurse's face. It is hard to describe.

Nothing existed outside of my little curtained space. I now started picturing more physical things in my life and somewhat realizing they were real. I still had doubt in my mind that all these things were simply my imagination and that only that plain of white was real. As I talked to Kate and the nurse more, I came back to the real world again. I felt like I had been gone for an unmeasurable amount of time. It could have been days, but I think I was only out for 5 or 6 minutes. I'm really not sure. I do barely remember at one point having an MRI taken, but I have no idea when that was.

I'm not really sure, but I think it was several hours before I felt fully grounded in reality. It was as if I had quickly gotten back to 95% reality, but the last 5% took a while.

Looking back, I think that "white plain of energy" was actually the white drop ceiling of the hospital room. I remember there being a grid in the plain and it was about the same size as the ceiling tiles. That seems rather dumb now.

Also, the experience was very reminiscent of the Matrix movie. This is not one of my favorite movies, so I really doubt the movie had any influence on my during this experience. If my experience is typical of someone on Ketamine, I would venture a guess that the person who wrote the Matrix was inspired by a Ketamine experience. Really, it seems like the Matrix is a Ketamine trip with a little plot thrown in.

So, that's my Ketamine experience. It wasn't that bad, but it wasn't that good either. I guess I would say it was unsettling. I wouldn't do it by choice, but if I needed it in a medical emergency I would say yes. When I went in for my surgery a couple days later I asked them to avoid using Ketamine during the procedure if possible -- it was very unlikely, but I wanted to make sure they knew how I felt.

One final note to end on is that the ER staff mentioned that Ketamine is actually used in children more. Yikes!

This is part 3 of 4 posts I have written about my elbow surgery. You can read them all here:
You can read them all here:
Part 1: The Emergency Room 
Part 2: Surgery and Recovery
Part 3: The Ketamine Experience

Part 4: Follow Up

Monday, June 22, 2009

Elbow injury - "terrible triad" - surgery and recovery

This is part 2 of 4 posts I have written about my elbow surgery. You can read them all here:
Part 1: The Emergency Room 

Part 2: Surgery and Recovery
Part 3: The Ketamine Experience

Part 4: Follow Up
In my last post I described how I broke my arm/elbow and the experience of the emergency room. This post describes what happened after the emergency room.

After the Emergency Room
In the days following the visit to the emergency room, I was drugged up pretty heavily on oxycodone. I was also taking some over the counter medication to counteract some of the side effects of the oxycodone. Oxycodone is a diuretic and can cause severe constipation. (I bet your glad you know that now.)

My arm was now pretty stable in a sling and splint made of cast material. The splint wrapped about 3/4 of the way around my upper and lower arm. My elbow was about 90 degrees. If I moved my arm away from my body it would hurt quite a bit, but as long as I didn't move it too much it felt okay. Again, I was on pain killers.

On Tuesday I went to the hospital to take care of all the
pre-surgery data. I met with a nurse practitioner and she talked with me about what I should expect the day of the surgery. The procedure I was having involved three steps. The surgeon was going to be doing an "open reduction and internal fixation" which from what I understand means that he would be opening my arm to put the elbow back in socket. Also, the surgeon would be reconstruction two ligaments. And finally, the surgeon would examine the end of my radial bone and determine if it needed to be replaced. We also discussed anesthesia and that I might get a "block" in my shoulder. From what I understand, it is a numbing agent (maybe Novocaine, I don't remember) that is injected directly into the nerve that goes to your arm. Essentially, it means you are under less general anesthesia, which can be good. The pre-surgery meeting was pretty quick and efficient.

Day of surgery 
My surgery was scheduled for 11AM, I believe. I could not eat or drink after midnight the night before surgery. I think they said I could have clear liquids or coffee, but I just avoided everything.

My mother went with me to the hospital. We checked in and went to the family waiting room. It was a little isolated from the rest of the hospital, had a pretty big library, televisions, free snacks and side rooms where you could get a little privacy if wanted. They gave us a pager, like you get at a restaurant and told us it would go off when they were ready for me. My mother would get the pager while I was in surgery and she
would be paged when the surgery was done. I haven't had a lot of experience with surgery in other hospitals, but I was very impressed by the efficiency and thoughtfulness that went into the process. It really made the process a lot more tollerable.

The pager went off and a tech took me to get ready for surgery. I was brought to a changing room where I changed into a hospital
jonny and robe. I was taken to pre-op. Here, they gave me an IV. I met the anesthesia team and circulating nurse for my surgery.

[My girlfriend works in the operating room at this hospital and she was able to request most of my surgical team. We had wanted a nurse
anesthetist (we have two friends who are nurse anesthetists), but instead I had a resident anesthesiologist.]

They gave me some drugs and wheeled me into the surgical room. I think they gave me the block in the
pre-op room, but it is a bit fuzzy. I remember being wheeled into the surgical room and looking around at all the people and equipment in the room. They knocked me out and the next thing I remember is waking up in my hospital room.

Post surgery 
I don't remember being in post-op at all, but I guess my mom was there briefly to say hi. Obviously, I was still out of it. I woke up in my hospital room and don't remember anything in between. It wasn't at all like the experience I had with Ketamine, which is good.

In my room, they gave me a "
PCA" (patient controlled analgesic), also called a pain pump and showed me how to work it. Essentially, I had a button that was hooked up to a machine and I could request more pain meds by clicking the button. The machine is programmed to not over medicate and I could get a dose every 7 minutes if I needed it.

I was very warm in the hospital. I don't know if it was really warm, or if it was because I was on a plastic mattress, or if it was a side effect of the surgery or drugs. Who knows for sure. Anyway, at one point, with the nurse's permission I changed into my boxer shorts and took off my hospital jonny. That made me a lot more comfortable. So, if you're having surgery, I would suggest bringing some shorts or boxers to wear.

Kate, my brother and his Fiancee, and my mom came to visit. I was still in a bit of pain and I probably wasn't too much fun to visit. After a while I decided to get some sleep.

PCA - torture device?
 So, at first I thought the PCA was a great idea. If I was in pain, it would help me out and I had some control over it. My opinion changed later that night. The PCA is configured to only dispense once every 7 minutes. I think they do this so you can't easily remember when you can hit the button again. The night after surgery was horrible. Here is what happened all night long. I would hit the button a couple times and get my pain under control. I would then fall asleep for a small amount of time. Then I would wake up from my sleep in severe pain. I would then have to click my PCA button and wait seven or 14 minutes to hit the button multiple times. Eventually my pain would be under control and I could fall asleep again only to repeat the process. Sometimes, I would use the pain pump too much and it would start beeping. I would have to page the nurse to get the beeping to stop. I don't remember how many times I went through that process, but it felt like the night took forever to pass.

The PCA was horrible. I had no information about when I could get another dose. I had no information about how many doses were left, and the doses didn't last long enough for me to get a decent sleep. By the time morning came I wanted to throw that
PCA thing out the window.

The Morning After 
The following morning, I was still in a decent amount of pain. The surgeon came and visited me and did some evaluation and explained how the surgery went. It turned out that the end of my raidal bone was broken into so many pieces it was beyond repair. He had to replace it with a fake bone. Because of the pain I was in, he thought I might have to stay another night in the hospital. That was a little disappointing.

My mom came to visit and said I should ask the nurse if she could do anything for the pain. The nurse took gave me some IV pain killers and started me on some
oxycodone pills. She took me off the dreaded PCA machine. The pain killers kicked in and I felt a lot better. I really started to feel like myself again -- the pain wasn't bothering me at all.

The occupational therapy person came to show me some exercises and how to take the sling on and off. I said I was thinking about leaving the hospital that day and she said that was fine with her and got the ball rolling to get me released. Kate was getting off from work at 7 that night and my brother was coming to visit at the same time. I was released from the hospital and my brother drove us home.

I spent the next several days taking my pain
meds every two hours and sleeping a lot. I spent most of the time in bed or on the couch watching television. My surgery was on Wednesday. I came home on Thursday and did essentially nothing until Monday. I slowly reduced the amount of pain killers I was taking. On Monday I was able to do some work (I work from home) and it made me feel much better to be doing something normal. It also made the time go by much faster. 

This is part 2 of 4 posts I have written about my elbow surgery. 
You can read them all here:
Part 1: The Emergency Room 
Part 2: Surgery and Recovery
Part 3: The Ketamine Experience

Part 4: Follow Up

Sunday, June 21, 2009

Elbow injury - "terrible triad" - the emergency room

This is part 1 of 4 posts I have written about my elbow surgery. You can read them all here:
Part 1: The Emergency Room 

Part 2: Surgery and Recovery
Part 3: The Ketamine Experience

Part 4: Follow Up

Three weeks ago I broke my arm/elbow. I thought I would document my experience so far.

How it happened 
I was on my road bike, with my feet clipped in. I was going up onto a curb and had to avoid a fire hydrant on the sidewalk. I was not really paying attention. My rear wheel did not make it onto the sidewalk and slid along the the curb a little bit until my bike abruptly stopped. At this point I tipped over with my feet still clipped in. I put my arm out to break my fall. My hand hit and I immediately felt my arm do something it should not do. I rolled over grabbing my arm and immediately yelled "Call 911" at my girlfriend, Kate, who was biking behind me.

Emergency Response 
The first couple minutes were not too bad. I laid on the pavement and kept my arm as steady as possible. It was across my stomach. My girlfriend called 911 and after some discussion about what town we were in an ambulance was on it's way. It turned out we were right on the border of Newton and Brookline. They directed the call to Brookline's 911 center and in about 5 minutes the Brookline emergency services showed up.

Everyone was very nice and asked me about 10 times if I had been wearing a helmet -- and I had been. After a couple minutes, they got a stretcher. I got up and walked to the stretcher with no problem. The ride to the hospital was uneventful. The driver and medic made corny jokes the whole way about how fast they were going and if I wanted to drive, etc. I think this is part of their spiel to keep the sick person awake, but I am not really sure. They got me to Brigham and Women's Hospital (by my and Kate's request) and got me right into the Emergency Room.

Emergency Room

In the emergency room they started an IV and gave me some pain killers. Up to this point I was only really in pain when my arm moved. After what seemed like a long time, I was taken to get x-ray images of my elbow. The x-ray process proved to be very painful because they needed me to move my arm around to get images from different angles. When the first image was taken, I heard the technician let out a gasp when he saw the picture come up. That is never a good sign. After 2 images were taken and I was in excruciating pain, I thought the technician said she needed to take one more image. I jokingly responded that I was beginning to hate her. She laughed, and said that actually we were all done for now.

I was wheeled back to my emergency room area. They examined the x-rays and determined that I had dislocated my elbow and that they were going to try to put it back in socket. They also warned me that sometimes these injuries are so bad that they require surgery. Yipes.

Conscious Sedation
They decided they would give me something called conscious sedation with a drug called propofol. Essentially, it would knock me out for only a couple minutes and they would put my arm back in its socket. Once they got the drugs from the pharmacy, they started the process. There were about 6 people in my room and they started giving me the drug. Every so often they would ask "Are you still with us?" and I would respond "yes". Eventually, they decided I wasn't going to go fully unconscious and tried to set my arm while I was still responding. They yanked on my arm and got it back into socket, or so they thought.

It turns out they had given me enough propofol to knock out a 200 pound person. They were very surprised that I was conscious through the whole thing. I believe I was actually the talk of the E.R. for a brief period. "Did you hear about the guy that talked through propofol?" I heard they even searched on Google to see if they could find something similar. They think it might have been because the blood pressure cuff was on the same arm that they were giving me the propofol. I remember the entire thing, which I guess is unusual.

Second Attempt
I went back for a second set of x-rays. When they lifted my arm to get an image, I (and the technician) felt my arm slip out of socket. They brought me back to my ER room and tried to put my elbow back in place again. It just wouldn't stay. They decided they would have to really yank on my arm to get it back in place and that I should be really knocked out for that. They decided on giving me Ketamine.

Third Attempt
The did a safety pause, which I thought was cool and then gave me the Ketamine and I was knocked out. I hallucinated and everything. (I will go into more detail on the Ketamine in another post.) It was very interesting, but not something I would want to do again. While I was knocked out, they put my arm back into socket. They also took CAT scans, which I vaguely remember.

So, my arm was back in socket, and my arm was in a split made of cast material. I also had a sling to hold my arm. The Ketamine eventually wore off, and I was given some pain meds. I slowly began to recover. Eventually, at 3AM we left the Emergency Room. They told me a doctor would look at my x-rays and CAT scans to see if I needed surgery.

 The next day a doctor told me I would need surgery to fix my elbow and scheduled surgery for Wednesday. I will go into detail on my surgery in a follow up post.

Of course, it was not a fun thing to go through, but I have to say that everyone involved was very professional and friendly through the whole process. The staff at Brigham and Women's Hospital were great and I really appreciate the work they did. The emergency response crew was also great.

This is part 1 of 4 posts I have written about my elbow surgery. 
You can read them all here:
Part 1: The Emergency Room 

Part 2: Surgery and Recovery
Part 3: The Ketamine Experience

Part 4: Follow Up

Triathlon update - broken arm

Well, this weekend was the triathlon I was training for. Unfortunately 3 weeks ago, I fell while on my road bike and broke my arm. I'll go into more detail on that in another post.

So, unfortunately, I couldn't participate in the race. I will have to find a race in the fall that I can enter.