1/19/03
Paul and I delayed departure from Toronto 1 day since the last MoreLife update took longer than expected. Once the upload was complete, our attention turned to packing our clothing and food for the drive to my house in Arizona. At approximately 11:00am Wednesday 1/8/03, with our new WRX wagon expertly packed (Paul's doings, not mine), we were off. I thought I'd be writing here about our trip and the first few days of settling in, but much to our surprise, the events beginning the evening of Saturday 1/11 at about 9:00pm far overshadowed everything preceding since leaving Toronto.
We had successfully found a very good used desk to unexpectedly replace one of the two we had set up in our "office" in the basement of our house. (Yes, there are some houses with basements in AZ.) For lunch about 4:00pm we modestly partook of a new Chinese buffet in Casa Grande and then did our necessary grocery shopping. While we ate some of almost every meat/vegetable selection, Paul and I ate only enough to feel satisfied. Despite this, we were both still full about 9:00pm when I began to experience a great deal of belching and abdominal cramping. Instead of subsiding in the next couple of hours, despite Maalox and Pepto Bismol, the discomfort increased; I then vomited some of my undigested lunch.
Our first thought on the cause was a reaction to something I ate at the restaurant. While initially I couldn't think of anything I'd eaten that Paul had not, I did realize in the wee hours of the morning that I'd consumed 3 cold shrimp before a bit of desert, while Paul passed them up. By this time it had been several hours since I'd passed any rectal gas after a small amount of diarrhea soon after the vomiting. In the meantime my abdomen was bloated and cramping painfully, but my temperature was not above 98F (and my appendix had been removed at age 13). Two tylenol with codeine taken about 1:30am took the edge off the pain sufficiently to allow me to doze for an hour, but then the pain was back with noticeable amount in the left flank, an unpleasant added feature.
Although I was considerably restless, walking about our bedroom and bath and only able to lie down for a few minutes at a time, I still didn't pass any gas. My symptoms no longer appeared to be gastro-enteritis. I had urinated several time without pain and the urine was clear, leaving me with the concern that I had a bowel obstruction caused possibly by volvulus (twisting) or intussuception (telescoping) of the bowel, although I had not vomited any fecal-like material.
Since the symptoms were not clear cut and were abdominal, rather than say a simply lacerated extremity, that pretty well ruled out the use of a stand-alone urgent care center. So about 6:30am Paul took me to the Casa Grande Regional Medical Center - driving according to my directions several roads with which he was only slightly familiar.
Thankfully, the ER was empty of patients or family in the waiting room and I was "triaged" immediately and placed in a treatment room. I continued to be in considerable pain and unable to lie in any one position more than a couple of minutes; I was allowed freedom of movement within the treatment room and not required to remain on the stretcher. Following the physician exam, blood-work, "production" of urine sample in the bathroom (cloudy for the first time), and start of an IV, X-rays of my abdomen both upright (standing with knees bent was the best I could do) and supine (flat on my back, but with slightly bent knees to reduce the pain) were managed without pain medication because they required I only be still for seconds. Since multiple gas-filled loops of bowel obstructed view of the primary abdominal organs, a computed tomography (CT) scan of the abdomen was ordered. This could not be performed until my pain was controlled sufficiently for me to lie without moving for the few minutes necessary to ensure complete data collection for a good viewing. Morphine sulfate given intravenous through the IV tubing, took enough of an edge off the pain that this could be accomplished. (Actually lying in the required prone position for this imaging was more "comfortable", as also was lying directly on my left side - now the most painful area.)
Although the ER physician was not generous with his explanations, we did learn that the CT scan indicated a stone in the left ureter with back-up of fluid into the kidney. I was to have an ultrasound of the abdomen to rule out any other problems and he would be notifying my family doctor. The ultrasound was especially uncomfortable when the technician ran the "pick-up" instrument over my left flank, even though she was trying her utmost to be gentle while gathering good data. I was then admitted to the hospital under the care of Nabin Sharma MD, the partner of my primary physician (Dr. Murali Talluri), with a urological consultation ordered - my urologist for approximately 10 years (I had a long history of bladder infections (cystitis), but none in the past 2 years) was not on call that weekend and I chose to wait until Monday to see him rather than the physician covering for him.
Upon reaching the Medical Unit with a capacity of 25 patients, Toradol (Ketorolac) a non-narcotic anti-inflammatory intravenous analgesic that specifically provides relaxation to the smooth muscle of the ureter was ordered by Dr. Sharma who saw me for the first time (he had only been in the area 6 months) soon afterwards in the room; it was given to me starting at noon. The first 2 of these every 6 hour doses significantly controlled the pain, allowing me to relax in the bed and actually sleep approximately 3 hours after Paul left at 8:00pm. I had also urinated several times into the "hat" placed under the toilet seat, and strained my own urine out of professional curiosity, but no stone was passed. However, the third dose (of Toradol) at midnight and the next at 6:00am appeared to have little effect, even with the addition of morphine at 4:00am. (Morphine has a "counterproductive" constricting effect on the ureter, so I delayed asking for it.) I was unable to relax again sufficiently to sleep and traversed the halls several times pushing my IV pump, since standing and walking were less uncomfortable than lying in the bed. During all this time I was allowed nothing to eat or drink - simply a few ice chips, but that was all I really wanted.
Dr. Paul Fieldstone, my big teddy bear (while he is tall he is not overweight, but definitely very likable) of a urologist with whom I'd had many intelligent discussions over the years of my intermittent bladder infections which I self-treated under his direction, appeared in his typical surgical greens mid-morning. He had taken a quick break from his office located on the hospital grounds to look at my various imaging studies and had brought copies of the reports for Paul and me to read. We scanned them quickly as Dr. Fieldstone drew attention to the moderate to large left hydronephrosis with left hydroureter - both the kidney and ureter were fluid enlarged. A small amount of urine was seen behind the left kidney having leaked through the tissues because of the pressure build-up. The cause of the fluid back-up was seen to be a 5 mm stone near the bladder end of the ureter. (The degree of the hydronephrosis was made evident to me when I later read the report in its entirety including the measurements of the L kidney, which showed it to be increased in volume 46% over the normal appearing R kidney.) His strong recommendation was removal of the stone via the bladder (cystoscopy); a laser would be brought from Phoenix to pulverize the stone (lithotripsy) if intact removal was not possible. An "S" shaped stent would be placed to keep the swollen ureter open to allow for urine flow for a week or two after the removal, with its end free in the bladder allowing extraction in the office.
The explanation Dr. Fieldstone gave for my quiet large intestines (paralytic ileus) is that the same nerve pathways between the kidney and brain also serve the large intestines. The normal reaction of the brain to the severe stress placed on the kidney by hydronephrosis (or likely other significant insult) is to reduce the impulses to organs on the same path. Therefore much of my small intestines continued to rumble producing lots of gas which either I belched or was collected (because there was no peristalsis throughout the intestinal tract) in the remaining loops and in the bowels - the large intestines, which start where the appendix is located.
Paul and I were quite agreeable to the procedure; I felt somewhat relaxed that the cause was clearly identified, a procedure for treatment was planned and that I had a very competent physician. We need now only wait till the formality of authorization and scheduling were complete.
About noontime, Dr. Fieldstone returned with the authorization for signature and the anesthesiologist. The latter's questions were the usual for a pre-operative interview: my surgical history, when I'd last eaten, and what medications I was taking. Paul had brought to the hospital on an earlier trip, printouts of my Regimen which the anesthesiologist immediately began to examine. Within a couple of minutes he was raising objections to the surgery because I had been taking American Ginseng - 3 times daily up until 36 hours previously, the time of my last meal. His reason was based he said on a national guideline that general anesthesia not be given within 2 weeks of American Ginseng use due to its "ephedrine content". Our counter arguments were that American Ginseng contains little ephedrine (in fact, we have since found no evidence that it contains any) and is not comparable to other herbs like ma huang, that I'd had successfully undergone general anesthesia for shoulder surgery 2.5 years previously after withholding the herb only 5 days, we were willing to sign an additional release, that I did not have any history of heart arrythmias (which was the potential side effect) and that my individual medical history and physical should take precedent over any generalized guideline. Dr. Fieldstone intervened, asking if a spinal would be a viable option; I frankly stated that I had a serious concern regarding a spinal as I had suffered a severe headache following the one experience with this type anesthesia I'd had many years previously. Dr. Fieldstone acknowledged that delaying the procedure, either with or without placement of a nephrosotomy tube (directly into the kidney to drain it) might not result in kidney damage, but that this was a risk and would also necessitate a repeat of laboratory and imaging work-up prior to the eventual stone extraction procedure.
At this point the anesthesiologist said he wanted to discuss the situation with his department chief. Dr. Fieldstone urged the need to decide quickly because he would be required to cancel the laser no later than 3:30pm; at that point the anesthesiologist hurried from the room. Assuring us that he would call to check on the status of the situation, Dr. Fieldstone left to return to an office full of patients. I turned to Paul and sighed that I probably had no reason to be concerned about after effects of spinal anesthesia these days; I'd agree to it if that was the only way to have the surgery.
As it neared 3:30pm, I walked down the hall to the nurses' station to ask if Dr. Fieldstone had phoned. (Paul had gone off to complete some errands.) Before my assigned nurse could answer, there he was approaching the desk with a tall younger man - also garbed in surgical greens - close behind. I started to offer my agreement to have the spinal anesthesia for the stone extraction, but Dr. Fieldstone immediately cut me short with a "Wait and listen". He had just been re-examining my ultrasound from the day before with Brian Zernich, an interventional radiologist. This was an area with which I was not familiar and learned from Dr. Zernich that this 10 year old specialty covered a number of procedures that had previously been performed by typical clinical physicians. Together they explained that Dr. Zernich was concerned that the increased pressure - although of short duration - created up the ureter to the kidney during an extraction procedure would cause more fluid loss from the organ directly and therefore more damage. He highly recommended that he "drop" (insert) a nephrostomy tube allowing the kidney to drain and "cool off" (ie reduce inflammation) for a couple of weeks. Dr. Fieldstone stated that after consulting with Dr. Zernich, he agreed that the nephrostomy tube was the best approach for the health of my L kidney in its present state. I was agreeable, although I explained to Dr. Zerkin - now alone since Dr. Fieldstone had again hurried back to his office - that I wanted to explain this new approach to Paul before I signed authorization. As to how soon this procedure could be performed - under a well sedated local - Dr. Zernich explained that the specific room needed was then in use but that he'd be rearranging the schedule to make it available within a couple hours.
It was over 30 minutes before Paul returned and when I finished explaining the most recent turn of events, he had a question about whether the kidney would require suturing when the tube was removed, something I'd not thought to ask, though I didn't remember that being the case "in the old days". Not wanting to ask questions in the semi-public atmosphere of the nurses' station, I used the call button and asked that the nurse assigned to me, Laurie, come to the room with the permission form. A few minutes, Laurie called down on the intercom that the radiology nurse was on her way with the form to my room. For the next 15-20 minutes, Debra explained the procedure once again to Paul and added details of aftercare of the nephrostomy tube that I then thought to ask. She also explained that the table in the "Specials" room was being troublesome and it would be at least a couple more hours before the procedure could be performed. There was also a possibility that table repair might not be able to take place until the morning, but that she'd come back and let me know personally if that was the case.
Paul and I kept up each other's spirits as we began an indefinite wait. The intravenous Toradol had continued but still with little pain relief, although all the distractions had kept me from dwelling on it. I alternated between bed, chair and walking, and worked an outside issue with Paul that by itself was a major problem. We definitely did not seem to be without "challenges" in the first few days of our 3 month stay in Arizona. As we returned from yet another walk in the halls, there was Debra approaching from the other direction. She explained that the table continued to malfunction and that a special repair technician was scheduled to arrive early the next morning. Therefore, the procedure was postponed until at least the late morning, if not the afternoon.
Before I could really adjust to the new situation, an x-ray technician was there with a chair to take me for a repeat flat plate of the abdomen ordered by Dr. Fieldstone. The one taken the day before was poor due to my more severe pain at the time. Less than 1/2 hour after returning to my room, the imaging technician who performed the CT scan the day before was there at my door with a wheelchair and I was off again for a repeat of the abdomen. Although I was in considerable pain and feeling a bit shaky, I was able to climb onto the table and arrange myself on my stomach - still a less uncomfortable position than on my back, as was needed for the abdominal flat plate. I couldn't manage to hold my breath quite as long as ordered by the automatic recorded instructions, but apparently it was sufficient. I lay there on the table with my arms extended over my head waiting after the table had moved through the chamber. I couldn't hear any voices, but when I raised my head and looked toward the control room, I could see several heads directing their attention to what I knew was the computer monitor and Paul standing in the exterior doorway just beyond them. Finally the technician returned and helped me off the table and into the waiting wheelchair telling me that Dr. Fieldstone and the radiologist were conferring. I immediately registered my strong interest in seeing the scan myself and walked to the control room. Dr. Fieldstone and the radiologist (not Dr. Zernich) had the technician run the previous day's scan pointing out the enlarged left kidney, the fluid behind it, and the stone location. The scan just taken showed less fluid present, indicating some healing on the part of the kidney. Dr. Fieldstone now felt that the removal of the stone could safely be done and that waiting until the next afternoon for the less beneficial delaying action of a nephrosotomy tube was not desirable. He would now be able to give a good clinical reason for the stone removal outweighing "guideline" restrictions on general anesthesia. I should be on the OR table in less than 2 hours.
Paul and I were greatly relieved; this procedure would eliminate the problem and I could go home the next day. About a half hour after my return to my room, I signed the operative authorization and in less than another 45 minutes an OR technician was there with the stretcher. Paul walked alongside as I lay on my left side to minimize the pain. He was to wait in the ICU waiting room until Dr. Fieldstone completed the procedure - estimated for 1 to 3 hours.
In the hallway outside the operating room being readied for me, I was covered with warm blankets when I complained of being cold. The nurse did a last check, verifying identity, allergies, and which kidney was involved - she wrote the word "NO" on my right flank. When she asked me about dentures, I added to the "no" I had given twice before, information I'd not thought of earlier - that I had moderately large bone growths on the interior surface of my lower jaw under my tongue. The nurse called over the anesthesiologist - the one who had raised general anesthesia objections earlier in the day. With a friendly smile he greeted me and looked inquisitively at the protrusions which dentists had told me would present me with no problems unless I ever needed dentures, which I was conscientious in preventing.
I was sufficiently at ease to converse with the nurse whose career extended back to the days when I did my last part-time nursing assignments in the predecessor to the current hospital. She even knew the nurse who often relieved me on those every-other weekends at Homako Hospital, another "Kitty" and would be passing along a "Hi" from me.
It was time - the technician had finally arrived from Phoenix with the laser and I was wheeled into the OR alongside the table. It was being covered with a warm bath blanket - a comfort greatly appreciated, as I felt cold immediately as I began to move myself those few inches from the stretcher. As I lay on my back, warm though still in pain, I looked at what I could see beyond my feet both to the right and left. Although I'd never worked in the OR as an RN, I'd enjoyed my 3 months experience there as a nursing student and everything looked familiar. Even a laser was familiar to me I mused as I looked over towards the young man in scrubs resting his hands on a large blonde colored case; he was answering Dr. Fieldstone's question regarding his trip south from Phoenix. The thought passed quickly through my mind that I'd used laser interferometry several times for failure analysis as a mechanical engineer with Motorola. I considered the single frequency, phase coherent light an "old friend".
My left hand, with the IV in place, was brought out from under the warm blanket in preparation for installation of short-term anesthesia rendering me unconscious prior to endotracheal intubation. A clip was attached to my left index finger; it would provide blood oxygen content data during surgery and immediately post-op. The anesthesiologist, surgical mask in place, was looking down over my head explaining as he placed a clear mask over my nose and mouth that I was receiving oxygen and would be asleep from the medication being "pushed" into my IV. I was calm - most likely because I was both tired of hurting and confident that Dr. Fieldstone and the team assembled would relieve me of an unwanted 5mm object blocking my left ureter.
My next conscious thought occurred as I opened my eyes and focused on the ceiling with a mask - a different one I realized - over my nose and mouth. I didn't have the pain that had been my constant companion since the preceding Saturday evening. My gaze fell on the clock hanging on the wall to my right - it was 8:45pm; I estimated that I'd been under anesthesia about an hour. I heard Dr. Fieldstone call out to me when he was told I was awake - he'd been able to grab the stone with a "basket" and had not needed to employ the laser. The anesthesiologist looked in on me and related that the intubation had been a bit difficult; I was glad I had thought to inform him of the space-taking bone growths under my tongue, even though I'd not been advised of any difficulty with the anesthesia for the shoulder surgery in October of 2000. My throat was a bit scratchy but not excessively so; the Recovery Room (RR) nurse spooned me a delicious ice chip upon request.
My stay in the RR was uneventful and about 9:30pm I was wheeled out into the hall where Paul quickly was at my side broadly smiling and squeezing my right hand. On the brief trip back to my room he told me that Dr. Fieldstone explained that the stone with its rough surface had been wedged into the ureter but was freed easily during the momentary ureter expansion he created with pressure. This meant that we'd be able to know its constituency and adjust my diet, activities and supplement regimen accordingly to do our utmost to preven a recurrence.
I scooted myself from the stretcher to the bed with the only incumbrance being the indwelling urinary catheter that had been inserted in the OR - an item I had expected. An antibiotic was added by way of a supplementary container to my continuing IV; doses would continue every 6 hours. Paul stayed with me that first hour as the aide came around every 15 minutes - not to take my B/P and pulse, but to simply record what was taken automatically; an advancement from the "old days". I requested and enjoyed a container of jello and cup of orange juice as Paul chuckled at my savoring mannerisms; a definite cut above ice chips. I also passed a bit of intestinal gas (flatus) - the first since the small bowel movement in the first hours of pain Saturday night. It was a reassuring sign that nerve signals to my intestines from my brain were returning to normal.
It was now nearing 11:00pm and I insisted that Paul return to the house and get some greatly needed sleep. He didn't need much convincing and assured me he would return around 9:00am in anticipation of my discharge.
While I was free of pain, I found myself unable to fully relax mentally in order to fall deeply asleep. I awakened several times each hour, aware of the time passing on the clock on the far wall, the grotesque cough of the woman in the room on the other side of the wall behind me, and occasional alarm signals from IV pumps in other rooms.
At 4:30am an aide came by for another set of vital signs which had progressed from every 30 minutes 3 hours previously. My IV pump alarm sounded a short while later indicating a low volume and need for "bottle" replacement - gone were the typical glass containers I remembered for most of my nursing career. When the nurse came to hang a new bag, I asked for some pudding - I was hungry and any flavor would do. She was back in a few minutes with chocolate which I proceeded to savor as I had done with the jello some 5 hours before.
I passed flatus a few times as I lay in the bed, turning from side to side and sitting up periodically purposely to help stimulate large intestinal peristalsis. Since I couldn't sleep, at about 5:30am I unhooked my foley bag from where it hung on the right side of the bed and held it low as I sat on the edge of the left side. I then stood up. (I don't recommend an unassisted first time venture out of bed following surgical procedures. However I was experiencing no pain, nausea, or dizziness and was prepared to retreat back down on the bed should any of these occur while I stood first for a few minutes before doing any walking. After moving around the room to the IV pump electrical cord's maximum extension - and feeling no discomfort - I pulled the plug from the wall (as I had done for hall walks the night and afternoon before) and proceeded into the hall. It was good to be out of the confines of the bed and the room, even though it was a comfortable size single.
I felt good as I walked down the hall pushing the IV pump and holding the foley bag; good enough that my stomach reminded me that it would like "more". I presented myself at the desk and let the nurse assigned to me know that I would like a soft breakfast. My orders read "full liquid, advance as tolerated", so I was announcing my readiness to "advance". Breakfast, when it did arrive some 90 minutes later, was filling but a bit of a disappointment since the only fruit was orange juice.
With my stomach pleasantly full, I was anxious to see Paul and leave as soon as Dr. Fieldstone gave the word. On the return from my third walk down the hall towards the front entrance, Paul caught up with me. He still looked somewhat tired but far better than when he had left late the night before. A few more hours of sleep could have been Paul's since I didn't actually get seen by Dr. Sharma, my admitting physician, until 12:30pm. Dr. Fieldstone telephoned from his office about the same time explaining that his stop on the Medical Unit after completing his OR schedule was thwarted by a considerable water leak in the main hallway outside the unit. (Paul and I had seen maintenance activity near the intersection of corridor leading to the front entrance on one of our several hall excursions while waiting.) He left concurrence for discharge and instructions for an antibiotic prescription to be written by Dr. Sharma. I was also to see Dr. Fieldstone in the office before the end of the week and arrange an appointment for the stent removal.
It was just after 1:30pm Tuesday, January 15 when, with Paul at my side, I walked out of the front door of the Casa Grande Regional Medical Center - almost exactly 54 hours since, while grasping Paul's arm, I'd hobbled in pain into the ER of the same facility. We walked now a few hundred feet to Dr. Fieldstone's office where he quickly showed us the photos taken in the OR and I arranged an appointment for the stent removal on Thursday January 23rd. One more stop was on the list - a drive to the pharmacy to get the prescription filled, with a short trip to Office Max while we waited.
Finally we got back to the house just as my lack of sleep was becoming noticeable; it had been a stress filled nearly 2 1/2 days. I had no untoward effects from the stone removal procedure or general anesthesia up until that time. The following days saw one day of sore neck and shoulders from the intubation, another day before my bowels were regular, and bladder irritation developed from the stent. This last was a result of "too much" activity I learned when I spoke with Dr. Fieldstone on the phone on Saturday afternoon, although I had not been given any precautions.
All is being kept "under control" at the present by taking more rest then not; once the stent is removed I can get back to "normal". When Paul and I confer with Dr. Fieldstone on 1/23, we will then re-evaluate my regimen for prevention a recurrence of kidney stones. This has been another reminder that staying healthy is a constant challenge, even when one is spending large amounts of time on staying informed and putting that information into practice.
It has definitely been an experience - one I am relieved that occurred here, if it was going to happen at all. Being a former RN made much of this experience easier than it would have been without that first of my 2 previous careers. It also provided me with a greater basis for critique of health care providers. The care I received at Casa Grande Regional Medical Center was of very high quality and, in most cases, with great understanding for a person in considerable pain. My sincere thanks go to nurses on the Medical Unit to whom I was assigned - Heather, Connie, Laurie, Lori, and Deb; and the staffs of the Emergency Room, Imaging/Radiology Department (especially radiology nurse Debra), the Operating Room, and the Recovery Room. Thank you to Dr. Sharma, Dr. Zernich, and even the anesthesiologist who originally objected to giving me general anesthesia - they were each conscientious.
I am sure that I would have been in the hospital much longer and with much less satisfactory resolution of the problem if my urologist had been other than Dr. Fieldstone. There were times in years past when I had waited in his office because he'd earlier in the day "blown" his schedule due to a hospitalized patient. This time it was me and I am glad that he prioritizes his patients as he does; I'll continue to wait patiently whenever I am in his office. He takes the needed time, not just with me but all his patients, to ensure that they understand their condition so that they can be informed patients - the only kind that have the highest likelihood of profiting from the technology available even in relatively small hospitals in the US, like Casa Grande Regional Medical Center. My warmest appreciation goes to Dr. Fieldstone, a 1971 graduate of the University of Toronto Medical School - just down the street from our apartment.
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