Merlin’s Knee Surgery Recovery Story Part IV of V
Patient Trauma – Managing Pain After Knee Replacement
Through the haze of pain and sleeplessness that first week-end at the rehab center, several things happened in my head. The first is that I developed an intense fear of the rehab process, and secondly, I lost any sense of trust in the people around me and consequently in the entire healing process as outlined by the facility. My feeling was that I was not a person, and as a patient, I was somehow equated with a thing to which food and medicine would be administered, like some inanimate piece of raw material, based on some arcane logic that would legally indemnify them should an unforeseen problem arise. The pain regimen therefore had nothing to do with my need as an individual or with any sense of compassion for the fact I was crying and begging the staff to speak to the doctor on my behalf. The medicine administered was the minimum they were expected to do. Meanwhile my blood pressure kept escalating which is a known side effect of constant pain and sleeplessness. The doctor did not seem to think that it was a factor that needed to be addressed.
The quality of total care at Meritus was supportive and encouraging and permeated all levels of care. The system at the rehab center was not a holistic one so that while the physiotherapist was as competent as one could find, her level of care stood out in an environment that was not organized to meet the full range of patient needs. A situation that erodes the sense of personhood would significantly reduce the sense of purpose, and the will and ability to be an agent in the challenging path to healing. My last day at Meritus Hospital, three days after surgery, I could walk 200 ft. Five days at the rehab center, and eight days after surgery I could barely walk 50 ft.
There is an old Caribbean folk legend that if a woman is careless about how she disposes of her hair when she dies her spirit will have to travel far and wide to retrieve her broken hair before she can go home to the ancestors. Sometime on that Saturday the myth came to me and I had a kind of loose thought that I would not like to have to return to this place for my hair when I die. And a poem began to push its way through as I tried to adjust to the reality of my situation. I’ll share an excerpt:
I have left my hair in many places
In rooms anonymous and blithely forgotten
In corners where I cowered in loss and desperation
Pieces of myself thrown carelessly out of windows
And snarled on naked branches outside dens of cruelty
Where my faith was peeled raw and bleeding
And my soul learned simply to accept it.
Compassion (Managing Pain After Knee Replacement)
There were a couple of nights when I cried to a point of exhaustion and fell asleep but continued to groan in my sleep (as reported by the nurse on duty). One of those nights I had been crying for so long that the nurse who was doing rounds came in and held my hand. I could just hear her voice saying, “I’m so sorry, I wish there was something else I could do for you.” She gave me my meds and then sat at the edge of the bed and stroked my head until I fell asleep. I do not know her name but I will forever be grateful for her humanity. Later in the week, the duty nurse came to me one night and said, “I know this pain and I will make sure we stay in front of it tonight.” She brought the meds right on time throughout her shift. I am relating these little episodes to show that many of the people at this facility were decent individuals who approached their jobs professionally but maintained their compassion. But a health care culture that puts systems and policies ahead of patient need ultimately fails in their primary role as healers.
By Monday afternoon, after four days of agonizing pain with brief spells of relief when I did receive the meds, it suddenly broke through to me that I should call Dr. Salvagno’s office. The only name I could remember through the fog was Patti Hutchison, the surgery coordinator whose commitment and meticulous attention to detail in my surgery prep had left a lasting impression. Again I do not recollect the details but Patti later described to me how alarmed she was at the voice of a whimpering child at the other end of the phone begging her to get me out of there. She said I sounded nothing like the self-possessed, articulate woman she had interacted with on more than one occasion. I seemed to have regressed into the reactions of a child in a mere four days of uncontrolled pain! How does a doctor justify this? Patti reassured me that Dr. Salvagno will never allow this to happen to one of his patients and she will get back to me as soon as it was resolved.
Finally on Monday night, the pain regimen was adjusted to something that was reasonably close to what it was at time of my discharge from Meritus Hospital. I remain convinced that my inability to bend my knee anything more than 47 degrees by the end of that week had everything to do with the fact that I had lost all trust in the facility and any of its processes. Once I was away from that setting, it took less than one minute after warm up to bend from 45 to 50 degrees and I got to 60 degrees that same day in less than 15 minutes. There was the strangest dynamic at the rehab center. I am conscious of having a great deal of trust in the physiotherapist primarily because she tried so hard and was deeply concerned that the situation had begun to affect my emotional state. She ventured outside of the box to create strategies and exercises that would help me to execute some of the basic movements that were necessary. But I simply could not manage them. I now believe that I had developed such mistrust and fear of the rehabilitation space that my body refused to respond to any aspect of her treatment even though I was trying. There was a part of me that felt she should be rewarded with some success for all her efforts and I began to feel guilty. But my knee would not cooperate.
In trying to analyze the whole experience, there was one very interesting factor. At the height of the pain on Saturday and Sunday, I did no exercise at all. But some kind of survival instinct must have kicked in on Monday and though the pain management regimen remained the same, and I was unable to do any meaningful work with the physiotherapist, I completed two sessions on the X10 machine once the pain meds kicked in. The X10 log shows that in both sessions I managed to achieve a 60 degree knee bend working alone. Perhaps I should explain that the two types of therapy are different. With the physiotherapist, I was required to actively bend the knee myself. The X10 flexion is where the machine bends the knee for you to the level of your pain tolerance. The curious thing was that, once medicated, I could tolerate the pain of a 60 degree bend on the X10 one week after surgery; but I could not move past 45 degrees with the therapist for the entire second week. Yet the first time I worked with a therapist away from that rehab center one week later, I could actively bend my knee from 45 to 60 degrees in less than 15 minutes.
What was even more interesting was that though I was primarily apathetic about my environment, the nature of the preliminary exercises on the X10 allowed me to remain somewhat engaged. My take on this is that the X10 allowed me to reclaim some small part of my autonomy. It re-inserted my individuality into the equation – I worked on my own, when I chose to – so that my brain did not reject the idea.
I have heard many stories of botched pain management and resulting loss of motivation. How many patients were lucky enough to have had some kind of system at their disposal to keep them involved and self-motivated?
The fallout from those four pain-filled days was as complex as it was far reaching and might have stymied the entire rehab process. The upshot of the entire ordeal was that the crucial first week of rehab was lost, my optimism for recovery had died, I no longer trusted the rehab process nor the people around me, I recoiled violently from the idea of any kind of pain, and I was intensely afraid of having anyone near my knee. This was not a good place to be if I was about to embark on a long and often painful period of rehabilitation. I left the rehab center worse off that when I had arrived. This was pain management gone horribly wrong because of a culture that failed to incorporate individual patient need into their protocols. Not only was this bad medicine, it was cruel, irresponsible, and morally and ethically wrong. Luckily on leaving the rehab facility to go home, I was again placed within the Meritus system under the care of an incredible physiotherapist named Jason Smith.
In Part V (the final chapter in the story) we explore what a real recovery strategy would look like and how the X10 PMKR machine was incorporated into traditional recovery methods to quickly regain lost ground. But this was after I lost another week of comprehensive rehab because of Murphy’s Law…