Pre-Op and Surgery

I left off at d-day minus 3. Having come to terms with the necessity of surgery, I now had to inform my company about needing time off, have my dear wife arrange her time off and figure out the plans for child-minding for Friday so that my dear wife could accompany me. On the Tuesday of Opinion #3, I also received in the mail, the paperwork for the surgery center where I was going to be having the procedure. Lots of the same information as all of the other forms before, along with detailed questions about my (and my family's) medical history. It contained the pre-operative instructions as you would imagine. No eating/drinking or chewing gum (check out why) after Midnight of the Thursday/Friday, no alcohol 24 hrs before the surgery, come to the center with a responsible adult who will stay for the full time and drive you home. I was also to receive a call 2 or 3 days before the surgery for a more in-depth interview on my medical history.

As it turned out, I got the interview call on Thursday and she just asked the same questions that I had filled out in the paperwork, I imagine that they just want to make sure that they have covered their tracks.

During the few days before the surgery, I chatted with friends and co-workers about the pros and cons of the spinal vs general decision which seemed to be in my future. Of course my dear wife wanted me to have a spinal so that I could better empathize with her as it relates to her c-sections that she has had for the last 2 kiddos. Others said that the general was the way to go. I have to admit that I had heard the stories of people waking up in the middle of their surgery, some being unable to move or talk but having to endure the excruciating pain of the procedure. One of my co-workers even told me a story about her own foot surgery where she woke up just as they were making the incision! I knew that there were pros and cons of either method and I vowed to set aside my concerns and trust that I would be taken care of.

On Friday, my darling wife let me sleep in until almost 9am. That was a big help as I didn't have to get up at 6am and spend the morning being hungry and grumpy for the lack of breakfast and coffee. We has a nice morning together and then we all went to the library. More distractions to help get to the surgery time. We came home, I made peanut butter and jelly sandwiches for the family (and I don't care for pb&j so it wasn't a hardship to have to prepare them). I almost inadvertently ate a Cheese Puff while making the sandwiches but caught myself just in time. Our babysitter arrived and I kissed the kids goodbye and told them to be good.

When we arrived at the surgery center (about 10 minutes from our house) we were met by our pastor who had taken the time out of his schedule to come down and meet with us before the surgery. We chatted for a while (it turned out that his retinal surgeon was involved with building the facility that housed the clinic) and then he prayed with us and we were called into the patient area.

It was a nice, new center. and the triage/prep rooms were curtained off with comfy chairs to sit in. I had the usual barrage of questions, then I was connected up to an IV, and I sat for a while as they prepared the operating room. When the anesthesiologist came out he said that we were doing a general anesthetic and I let him know about my earlier concerns about the "waking up in pain not being able to move" fears and he put my mind at rest. Because of the nature of my surgery, he was not going to be using any paralytic agent, so if I did wake up too early (which he said was very unlikely) I would be fully able to move and alert people that I was awake. He said that when I was brought to the room, he would hook me up to some meds that would make my tongue tingle, the my arm might burn a little, then he would give me abut 5 seconds before I was out and that I would wake up in recovery with everything finished.

Then the surgeon came in, we reviewed the steps in the procedure and he let me know that Opinion #3 doctor had communicated with him and that he was likely going to put a Kirschner Wire in to keep my toe straight. He told me that he would come out and explain to my wife about how the surgery went when it was all done. He said that he hadn't decided on whether he was going to splint/cast my ankle but when we told him that we had 3 kids, we all agreed that it would be prudent to do something to provide stability (as even passive flexing of my ankle and toe could cause it to impair the healing) in the event that kids jump on the bed etc. Minutes later I was being walked back to the operating room.

The operating room was cold and bright with machines flashing and pinging. There were people milling around the room, and with my glasses off, I could make out my surgeon and my anesthesiologist but didn't know who the others were. It is a sign of the times that my first thought was "I hope these people are all covered by my insurance". I looked around at all of the equipment and was reminded of the Monty Python, Meaning of Life clip with the doctors calling for the machine that goes "ping" and the most expensive machine in the hospital because the administrator was coming (http://www.youtube.com/watch?v=lxOu1DyVQV8).

I lay on the bed and the anesthesiologist asked me if I was OK, I told him I was fine. Then he asked me what I did for work (while telling me that he was starting to administer the medication). I told him who I worked for, and noticed my tongue was tingling, then I started to explain what I did, but started laughing cause I couldn't really remember what it was that I did. Then I felt a slight burning in my arm and was about to tell him that I could feel the.... ZONK.

I woke up in the recovery room with the nurse asking me if I would like to have my wife here. I said yes and fell asleep again. Then I woke up again and was greeted by my dear wife. She said everything went very well. She had my netbook and plopped it in front of my saying that my Dad was chatting with her - I tried to type something but felt a little nauseous so I had her take it away. After a few minutes I was taking ice-chips and feeling more lucid. I'm not sure of the exact timing but before long I was in a wheelchair being loaded into the van. We stopped by the pharmacy and picked up my pain medication, stool softeners, aspirin (to prevent clotting) and my crutches.

I got home and went straight to bed. The post-operative instructions were to remain in bed with my foot elevated above the level of my heart for 48 hours. I am not allowed to bear any weight whatsoever on my left foot for at least 4 weeks and in 2 weeks I will return to the surgeon to examine the wounds, evaluate whether to leave the K-wire in until 6 weeks post-op and to determine if additional casting is required. I cannot drive until my 2 week visit but can return to work once I am coherent. I slept alright overnight but it was hard to get into a comfortable position.

On Day one of being in bed, I kept myself occupied by watching movies and TV shows on Netflix and my dear wife delivered brunch and dinner to my bedside. I feel for her though because she has had to watch the 3 kids all day while tending to me. Hopefully by Monday when I can move out to the sitting room, I can be of more assistance.

I got some phone calls from family and friends and a nice call from my pastor (I told him that we wouldn't be at church tomorrow and he agreed that it was one of those "OK to miss church" excuses - I'll catch part 3 of his "Old Testament for Dummies" series on the web). I also got a follow-up call from the surgery center checking in on me. Add to that the 40+ well-wishes via email and Facebook I certainly felt special today and I thank God for all of the family and friends that he has blessed me with.

On to Day 2 of horizontal recovery.

Opinion #3

With the memory of the search for the second opinion in the forefront of my mind, I set about finding a orthopedic surgeon with a foot/ankle specialty in the main metropolitan area closest to my home. I looked at the websites for the few major hospitals therein and happened upon an Orthopedic Institute. They had a good website which showed the specialty of each doctor, including a foot and ankle guy who was board certified, had experience in several countries and judging my his photo, had been practicing for some time. I called his office and the lady I spoke with was very kind and understanding. She immediately grasped the nature of my request and the timing aspects. She put me on hold while she consulted with the doctor and when she returned she said that the doctor had agreed to see me. She offered me an appointment at 9am on Tuesday July 27th. I jumped at the offer. No need for faxing referrals or any other nonsense.

Up until last year, I used to take a car/bus/ferry combination commute to work 4 days a week. In fact I hadn't been on the ferry since my last day working out of the office (I work from home now). So my trip on the 27th was going to take me on my normal morning ferry. I also just recently heard from a friend with whom I used to work and he had informed me that he now worked in downtown again. So, I made arrangements to meet him for breakfast before my appointment. I also let my commuting buddy (and church friend) that I would be on the ferry too. In the evening prior to going to bed, my son (having overheard myself and my dear wife discussing the plans for the morning) asked if he could come with me. I thought about it for a few seconds and pronounced it a marvelous idea. We got his backpack loaded up with toys and books and went to bed early(ish) in anticipation for the early start.

On Tuesday morning I woke up at 4 something and I got myself ready for the day, I woke up my son and we loaded our stuff into the car, We left early enough to swing through the Starbucks for coffee/hot cocoa. ($6) Then we drove onto the ferry ($15), walked up to the passenger deck and sat with our friend for the journey. My son was well behaved and I got to have some adult conversation until it was time to head back to the car. We drove off the ferry and proceeded into down-town. We parked in my old office building and walked to the cafe where we met up with my former co-worker. We used to have coffee/breakfast there quite often when we worked together and we both commented on how familiar it all felt almost a year since we all worked together. We said our goodbyes after we ate our food ($14) and chatted, headed back to the car and paid for the 65 minutes of parking ($13).

It was a short drive to the clinic which had underground parking in the building ($5). It was a very plush facility. When we got to the 7th floor, each doctor had their own receptionist and when I approached the appropriate desk, the lady behind the counter greeted me by name! I had the usual paperwork to fill out and had the obligatory triage/nurse checkup. My son played with his toys quietly when the doctor examines my toe and reviewed the MRI and x-rays. He said exactly what Ortho #1 had said at my last visit. Basically that I had torn the EHL, that there was probably a tiny bone fragment that pulled away with some of the tendon, that there was a small thread of tendon still attached and that the remaining tendon was frayed like a shoelace. He said that surgery now might fix it, but if I left it too long, the only option would to fuse and pin the joint. At last, 2 doctors independently provided the same diagnosis. I had prayed for clarity, and I think this was God's way of providing it. He then looked at Ortho #1's records and said he thoroughly agrees but that he would also recommend a temporary pin for 4 week s to keep my toe straight while the tendon healed. He said he would email or call Ortho #1 with his notes/opinion.

I thanked him and we went on our way. We drove home rather than taking the ferry back and my son was delighted to see airplanes, trains, construction equipment etc on the journey home. It was a nice day out - albeit somewhat expensive ($50+) not to mention the cost of the doctor (still to be billed!).

Feeling more at peace with the necessity of surgery, I got my head in gear for the procedure on Friday July 30th.

MRI Adventure and Review

While talking with Ortho #1 to arrange my revisit after the diametrically opposing 2nd opinion, I asked whether an MRI might provide some additional insight into what was happening in my toe. He agreed that it might help and arranged for me to have the scan on July 21st.

I figured that the MRI wouldn't take too long, and determined that it was not worth getting someone to watch the kids. I like having them with me and it is good for them to see that they are not the only ones who have to see doctors etc. I took all 3 kids with me, and we arrived at the appointment time. They were very nice at the imaging center and I was taken back relatively quickly. The lady asked me if I had someone to watch the kids (that was probably my first sign of trouble). I let her know that I didn't have anyone to which she said "ok, that's not a problem - they will have to stay in the dressing room while you are having the scan". Not being clear on what that meant, I agreed and we proceeded to the dressing room.

It was a small, clothing store sized dressing room with a door that opened into the hallway, across from the nook where the people administering the scans were working. I took off my belt, emptied my pockets, told my eldest (5 1/2 yr old) that she was in charge of the other two and that I'd be right back. As I was being walked over to the imaging room, the lady said "don't worry, we'll keep an eye on them". I thought that was nice of her, and figured I'd be done in a few minutes and the kids would probably be fine.

I lay down on the machine, put my foot into a holster that kept it absolutely still, and I was given headphones ("because it thing gets pretty loud"). I lay there listening to the radio for a minute or two until I heard the lady's voice:

"OK, we are going to start the machine now. We will run two tests in a row for the first past, each will be about 8 minutes. All together we should be done in about 45 minutes."

Ehhhhhhhhhh... 45 minutes for a 5 yr, 3yr and 1yd old to stay quiet and self-contained in a small box of a room with a handful of toys... that WASN'T going to work....

"I don't think my kids will be OK for that long"

"Don't worry, we will keep them occupied..."

Suffice it to say that I spent the entire time wondering what they were getting into. At the end of each section, she would say "OK, that scan is complete. The kids are doing fine."

Almost exactly 45 minutes later, we were done. I went across to the dressing room and the kids (thank you God) were in great form and had been very well behaved. We had to wait around for about 10 more minutes until they could give me a copy of the MRI images on CD. I took the kids to Red Robin as a treat and my dear wife joined us there.

On July 23rd I returned to Ortho #1 and he re-examined my toe and reviewed the MRI with me. He showed me the bone fleck that the Podiatrist called a fracture. He said that it is common on tendon injuries for tiny pieces of bone to come away with the tendon as it pulls off. The X-Rays and MRI show (in his opinion) that the tendon has pulled away from the bone with the exception of a fine thread which is why they tendon has not retracted into my foot. That was the good news.

The bad news was that the MRI confirmed his original theory that the tenon is damaged and will need surgery. As a tip of the hat to the podiatrist, he said that leaving it for 8 weeks might actually cause it to heal but being that is is 7 weeks after the injury already, the chances of it healing we low and waiting that long would probably rule out tendon surgery at that point, and the only surgical option would be to fuse the joint which would leave me with a straight, unbendable toe. He explained that the tendon had frayed at the end (somewhat like a shoelace with a thread that is attached and the remainder is bunched up around it). The procedure would be to disconnect the tendon, cut off the frayed section and re-attached to the bone with a clean cut. he showed me some MRI images but they were difficult to decipher but I got a sense for what he was saying.

I spoke to him about what the podiatrist said about surgery being wrong, and about orthopedic surgeons being scalpel-happy. He said that there is a historical rift between podiatrists and foot/ankle orthopedic surgeons. Basically it amounts to a difference of approach to treatment and that both has merit but that some people are more of a "fundamentalist" on one side of another. he likened it to Physical Therapists and Chiropractors.

I told him that given that I had 2 diverging opinions that I would like to seen a third opinion before surgery, but that we should proceed with making the arrangements for the procedure (to get on the books so to speak). He did some pre-operative examinations (listening to my heart etc) and I set a surgery date of Friday July 30th. He was very supportive of getting another opinion.

When I went home from my visit with Ortho #1, I recalled my experience with trying for find my 2nd opinion doctor and wasn't very optimistic that I would find someone who would see me between July 24th and July 29th but I proceeded with my search efforts. This time I decided to look close to the main cities close to my home. Again I spoke with 15 or more surgeries, each offering appointments in September as their only option. Then I had a bite!

I called a surgery (possible #1) and explained my situation, and the lady on the phone stated that their next available 'new patient' appointment was at the end of September, but after some discussions, she agreed to review my case with the doctor and asked me to hold. When she came back she said confirmed with me that I was looking to have the doctor provide his opinion on a diagnosis and that I needed to see him within the next week in order for it to be useful to me. I confirmed and she said that I needed to have my doctor fax over a "urgent referral" and they would be able to get me an appointment earlier than the "late September" date.

I called Ortho #1 and they said that they don't refer patients to other orthos and that I should have my primacy care physician do the referral. So I called my doctor, her office took care of the referral that afternoon. The following day I got a call (in the afternoon) from possible #1's office and they stated that they received my paperwork, and that the doctor has agreed to see me. The next available time to see the doctor was...... wait for it...... you know what's coming..... August 17th. I reiterated that I had surgery scheduled for July 30th.... that I has informed the person from the previous day of that fact... that by Aug 17th I would be over 2 weeks post-op.... She said "well that is the earliest you can be seen, if that doesn't suit you, then I'm sorry".

What a waste of time. Back to searching for opinion #3.

On the hunt for a 2nd Opinion

Finding an orthopedic surgeon for a second opinion in my area was going to be a challenge. Everyone that I asked pointed me back to my surgeon (Ortho #1). I looked in surrounding areas and called some to inquire about getting an appointment. Each call started out the same way:

"Hello, I have been told by my primary orthopedic surgeon that I need to have surgery on a tendon on my toe within the next 7 to 10 days. I am looking to get a second opinion before agreeing to the surgery. Do you have a surgeon in your practice who could see me on short notice to give me their opinion?"

I called 10, maybe 15 clinics and the answer to each one was the same:

"Our next available 'new patient' appointment is in September, does that work for you?"

Bear in mind that I started calling on July 16th. September is a month and a half away... It is not clear to me which part of "surgery within 7 to 10 days" they didn't get.

Eventually, I called an orthopedic surgery about 40 miles away and they said they had a specialist who would be able to see me. As it turned out he was a podiatrist which seemed OK to me as his website said that he specialized in foot reconstruction, toe rehabilitation etc. His next available appointment was into August, but the scheduler took pity on me and slipped me into his schedule early the following Monday morning.

When the day came, I drove out to the clinic and met with the Podiatrist. He seemed nice - had just returned from a 3 week vacation and I was his first patient. He took a look at my toe, and reviewed the x-rays (I had the images on CD from Ortho #1). His diagnosis could not have been more different than Ortho #1. He felt that my tendon was fine, and that I had a fragment fracture in the upper bone of my big toe. This accounted for the swelling and the lack of motion in my toe. He said bone fractures normally heal in 6 weeks, so not to worry about it. He also recommended that I get a set of prescription orthotics/insoles to account for my flat feet. He was actually far more interested in my flat feet and the orthotics than my toe. He also said that I could put a tight bandage around my toe for the next 4 weeks to help with the healing process.

When I told him what Ortho #1 said, he told me that it sounded like Ortho #1 was inexperienced with foot injuries and that "orthopedic surgeons like to operate first and ask questions later". He said that surgery was absolutely the wrong answer and completely unnecessary. He said that he would send a report back to Ortho #1 with his findings.

At the time it hadn't occurred to me, but it was pointed out later, that only a few days after my visit with the Podiatrist would be 6 weeks since the original injury. So in his estimation, my toe had about 3 days left to go from being bruised, bent over and immobile to fully healed...

I left the podiatrist feeling a bit lost. 2 doctors, 2 differing opinions. I wasn't completely convinced either way. The phrase "thats why they call it a practice" was running through my head; did either of these doctors really know what was wrong, or was each unduly influenced by the bias of their specialty? Determined to get a better answer, I immediately contacted Ortho #1 and arranged to see him again to discuss the 2nd opinion and what the next steps would be.

Why the Blog Name?

I decided to start blogging my experience of my foot "issues" that have have been having. The name comes from "Fumi and the Bad Luck Foot" (http://www.imdb.com/title/tt0493418/) which is a short film about a girl with very bad luck with her left foot. The title seemed to be almost perfect to describe my current situation.

To provide some history, at some point in the past (within the last 7 or so years), my dear wife dropped a can of Diet Coke on our kitchen floor. It developed some sort of puncture and sprayed the entire kitchen. It came to rest standing on its end, with a thin fountain of cola spewing high enough to reach our 16 foot ceiling. There, in the shower or soda, I started the cleanup effort. I was mopping the floor bare-foot (not sure why I thought that was a good idea) and within a minute or two, I slipped and kicked the underside of our dishwasher door with my left foot. Immediately I knew that it was a decent injury when I grabbed my big toe (which had born the brunt of the impact) and noticed how the sticky coke feeling quickly became a slimy blood feeling. dear wife grabbed a tea-towel and I suspect that she knew it was bad when I mentioned going to the ER! Trip to the ER, tetanus shot and 8 stitches in my left big toe later I went home to rest up.

Fast forward to 7 weeks ago. I was outside our house and slipped on some wet moss on the sidewalk. Wearing only flip-flops on my feet, I had a split-second choice to make on how to stabilize myself. I pushed my left leg out, caught the ground with my left big toe and planted my full weight on my toe, bent under my foot. It hurt. A lot. I hobbled back to the house (no doubt I was not using any bad language or anything) and informed my wife what I had done. It would seem that I hadn't broken anything because I could sort of move it - but it still hurt. I has a few scratches and a large bruise forming just under my nail-bed. I reseted for the rest of the day and the following day it seemed quite swollen, but again it was moving... sort of. Anyone I chatted with told me that I shouldn't both going to the doctor as they "can't do anything with toes" so I left it to get better. It didn't.

A week or so after the injury, I decided I'd better go to the doctor to see what she thought might be wrong (it was still swollen, the bruising was still bad and although I could walk, I had a pronounced limp). I saw a practice partner for our family doctor (who was out on vacation) who looked at my toe, said that it wasn't broken (because of how it was able to be moved etc) and that I probably just pulled something and it will get better in a week or two. She chose not to do an x-ray because she said there wouldn't be anything they would do anyway. She gave me anti-inflammatory meds and a course of antibiotics. I didn't ask any other questions and went about the following weeks as normal.

I returned to the same doctor 12 days later after the meds had run their course because my toe was still swollen, still bruised and I was still walking with a limp. She threw up her hands and said that she had exhausted her knowledge and referred me to an Orthopedic surgeon. Luckily, the doctors practice that I go to has several on staff so I assumed that I would get an appointment within a few days.... WRONG. The next available appointment with the only orthopedic surgeon in the practice that would see patients with feet problems was over 1 month out. I said that I would find another in the area. Thanks to Facebook, I got a couple of recommendations in the local area, and as it turned out, the only board certified foot and ankle ortho agreed to see me in 2 weeks.

Just a few days later, I lost my balance and planted my left foot, with full force, down onto the edge of an upturned piece of Barbie furniture that had been left on the floor. It cut a hole through my sock and lacerated my foot and toe. Back to the ER, this time they wanted to do x-rays to confirm that the wound was free of debris so I asked them to see if there was a break/fracture. They confirmed that the bones were intact. 14 stitches and a prescription for Vicodin later I was hobbling out of the hospital.

Fast forward 10 days to returning to my family doctor (now back from vacation) to have the stitches removed. I chatted with her about my toe issue, she took a look and wondered if there might be tendon damage. She was eager to hear the result of my appointment with the ortho (to whom she had directly referred people in the past even though he is not part of her practice). Tendon damage sounded bad - as my dear wife said: "that sounds like surgery is in your future". I sure hoped not. I looked up a bunch of online references including ways to prevent, identify, diagnose, and treat tendon damage. There were some commonalities, and my injury and symptoms were in line with many of the descriptions.

The appointment with the the orthopedic surgeon played out pretty much exactly as I had come to imagine it would. He looked at, pulled, pushed and bended my toe. He took some x-rays at his office which were immediately available to view on the monitor mounted to the wall in the consulting room. No broken bones. Most likely tendon damage. His first thought was Extensor Hallucis Longus (EHL) tendon was entirely ruptured and that it had likely started to retract into my foot. This tendon starts as a muscle in the front of your leg/shin and becomes a tendon before it runs along the top of your foot and connects to the bone at the tip of your big toe.

There is another tendon (your Extensor Hallucis Brevis) that connects to the lower bone in your big toe.

These tendons allow you to extend (straighten) your big toe. While other tendons on the underside (flexor tendons) bend your toe.

He felt that the best course of treatment was to leave it for a while to let the swelling subside, monitor if the the tip bends down too far or becomes stiff. And then do an operation to fuse the joint into a straight position which (with the use of the brevis tendon) I would still have some movement. Later that day, he called back and left me a voicemail to call him in the morning to talk about an alternative option that had occurred to him after I left.

The following morning I called, and spoke with him. He felt that a better option would be to transfer the brevis tendon to the top bone, thus keeping me with a moving joint and still enabling my body to flex and extend using the remaining tendons. The only drawback was that it needed to be done as quickly as possible to minimize the impact of the injury to the joint and other tendons (in particular that the joint could become stiff in the bent position and that the flexor tendons could contract through lack of use. I told him that I wanted to see a second opinion before agreeing to surgery. He agreed that would be a prudent measure on my behalf and said that we could arrange the surgery as soon as I was ready.