Surgery #2 & Post-Op Details #2

Surgery, Drugs, Pee, and Poop

Surgery

Surgery was easier this time for three reasons:
1) Been there, done that – reduced uncertainty
2) Better proficiency in relaxation techniques
3) The surgeon had less to do, resulting in less trauma

One thing not discussed in detail last time was the look and feel of things in the Operating Room. The room itself is huge, with tile walls, big round movable lights, and racks of instruments all around. Lots of empty space, too. They lay you out on the table in an arrangement that suits everybody working there – your comfort is handled only in a clinical sense. Sure, everybody is nice to you when you arrive, but the serious work begins when your lights go out. Then they can put things where they want. Couple of details – the table is VERY narrow, and you have to take care to center yourself from side to side. Your head is on a pillow, each arm is on a flat table that can be adjusted in many angles, your butt is in sort of a hole, and your legs and calves dangle off the end of the table into space. There are some stirrup things that go on your calves, but these are assembled after you are sedated. Before you go in, each leg is encased in a velcro sleeve with hoses – the purpose is to use a water massage to help with circulation. And you have a shiny shower cap to put on to help the body retain heat. It’s real cold in there – you don’t want people dripping sweat into the sterile field!

The unflattering picture below is NOT ME, but would be pretty similar if I were thinner…

NOT ME!

You can see the guy also has a tube going into his mouth. This tube is connected to a hard plastic airway that goes into the throat and the top of the trachea, allowing the anesthesiologist to control the oxygen and anesthetic gases coming in. Insertion of this device could never be done to a conscious person due to gag reflex, and it’s not too easy even when unconscious. Insertion and removal of the airway is why you always have a sore throat after surgery. Dr. Smith last time did a very nice job, and I had only minor throat discomfort. Dr. Petersen (or her student) did an awful job on me this time – my throat was very sore and I could hardly talk, plus I had a cut on my inside lip and gums as well. This actually did not bode well and did not turn out well later.

Drugs

Having spent a lifetime avoiding drugs for both recreational and medical purposes, I am alway astonished at the cavalier attitude towards indiscriminate use of alkaloids and other dangerous and potentially addictive drugs in surgery. I was initially sedated with a cocktail of drugs driven by Demerol, then kept under with a variety of gases and IV liquids. At the end of surgery they kicked me off with a dose of morphine, and the recovery nurse continued to add more over time. I questioned Nurse Millie about all the morphine, and she said it’s not a problem when only used for pain. I have no desire to have more now, so I suppose she was correct, but I’m still scared of the stuff.

You may recall that last time I had bladder spasms that were mostly relieved by a suppository. I asked Millie if that was coming. She checked the records and informed me, “They gave you a B&O suppository in surgery.” Being foolishly curious, I asked what B&O stood for. “Belladonna and Opium.” SAY WHAT? I recognized Belladonna from classical literature as a derivative from the “Deadly Nightshade” plant, popular in the olden days for committing murders and suicides. And opium? We all know what that is! To say I was startled at having all this shoved up my ass doesn’t really capture the feeling!! Later research wasn’t much more reassuring, listing over 20 alkaloids and narcotics present in the concoction! At least it explains the awful dry mouth symptom I had in recovery. Added to all this was the Lortab (codeine) that Nurse Vicki gave me as soon as I got back to Ambulatory Care. It’s astounding to me that I remember anything. And the reader should be advised that it’s possible that most of this story is a drug-induced fantasy!

PEE & MY RUBBER FRIEND – THE FOLEY CATHETER

If you did not read the previous post on dealing with the catheter, it is recommended FOR MEN ONLY. One striking difference from last time was when gas passed behind the bladder, just before evacuating. Previously it was quite painful for a few seconds. But this time instead of pain there was a VERY INTENSE urge to pee. And sometimes I even did squeeze some extra pee out the catheter. This symptom grew progressively worse over the two days I had the tube in. It would ultimately be a problem.

Knowing that I would have burning from the chemo treatment, I resolved in advance to hydrate maximally upon arriving home. As stated in the front page blog entry, the input at first far exceeded the output. What we are saving for the more discerning audience is the added detail that chemo drugs are a biohazard, and therefore so is the urine coming out of my body now. We were instructed to use DOUBLE rubber gloves when handling anything around the catheter, especially when draining, and to double flush the toilet. Nurse Vicki gave us a box of 100 gloves, and we found it nearly impossible to don a second glove over the first. Kathryn’s small fingers found a way to insert a second glove into an empty one, so she happily spent the evening creating a pile of double gloves. The one liter leg bag connects directly to the Foley at the top and has a twist valve at the bottom for emptying. Instructions say to use gloves to empty, but a little care can prevent contact with your hands or other skin. Double gloves seemed overkill, but I used them for a while. After the output ramped up around 10PM, it was quite the pain having to empty the bag with double gloves more than once per hour. At midnight I took a Lortab to try and relax and went to bed. Restless, I did not get to sleep right away, and at about 12:35 I felt a warm drop or two on my leg. Got up as quickly as I could and went to the bathroom and light to discover that the damn valve was leaking! So all this business of biohazard and double gloves is out the window now. Fortunately the damage was limited to the two drops on my leg and the bed was clean. Further research later revealed that the risk was a potential skin rash which never occurred. Necessity being the mother of invention, I needed a way to catch the overflow from the leaky valve in a watertight fashion. Having a good supply of rubber gloves now, and a rubber band, a solution was discovered. I moved from the bed to the couch to be nearer to a bathroom and spent the rest of the night with frequent trips to empty the bag, having to remove and replace the overflow glove each time. After about 4 times the leak seemed to clear itself, but I kept the overflow glove on for protection. It looked pretty ridiculous, but it worked!

As stated in the main blog, I have no idea how I survived a whole week with the one-liter “leg bag.” Maybe my hydration rate was lower, or I was too obsessed with the other discomforts to notice the hassles. I certainly made extra efforts to keep the tube spotlessly clean using soapy water this time, minimizing the sandpaper effect on the second night. The only reason I can think of to make the bigger bags “prescription only” is that it’s dangerous to empty more than one liter at a time from the bladder. When I was a CNA in the 80s, we would always stop the flow at a liter after instilling a catheter to let the bladder recover, then open it up later. But in my case this didn’t apply, being on continuous flow. I’m sure Dr. Hopkins would have approved the bigger bag, but the hassle factor was just absurd. Thanks to the stubbornness of my Texan wife to find a provider and procure the contraband. The Bard bag had a nice feature to make it easy to drain, with spring clip and a snap port to hold the drain. It also came with extra hose so you could hook it to the side of the bed. It was also nice to have only the hose to deal with when side sleeping, rather than the entire one liter bag. So I was able to get decent sleep on night #2. The absence of extender hose was the biggest obstacle to making a milk jug workaround! The illegal bag is pictured below.

Contraband – obtained without prescription!

After a better night’s sleep I was up at 7, waiting impatiently for the dogs to wake up Kathryn. She arose by 7:45 and immediately asked if I was ready to have the tube out. Boy was I! We set up a surgical pad (sort of a flat diaper, acquired from a drawer in the doc’s office during our last visit) on the bed under my lower torso, she donned gloves (for cleanliness, not biohazard) and I talked her through it. There was only one syringe of water in the balloon, and you could see the Foley collapse slightly when she pulled vacuum with the second attempt with the syringe. Good deal. The nurse had instructed us to just cut the valve off the Foley, but I preferred the mess free syringe method. I told Kathryn I would start it to make sure the balloon was empty, and she could take it from there. She was gentle and slow and it came out in about 10 seconds. Sweet relief! There was some residual dribbling, all caught on the pad. She wrapped the used Foley up in the pad and trashed it. Good riddance!!!

Now I was faced with the problem of re-starting a normal urinary process and at the same time needing to re-start the gastrointestinal process. All that pre-loading of fiber had not produced anything as of yet. Foolishly I thought I could get the urine going first, then attack the other end. Often when getting a Foley out the biggest concern is the difficulty to initiate a stream leading to an overfull bladder and need for another catheter. Last time I had an hour ride home to slowly hydrate, and the first couple of times were pretty hard to start. Some burning ensued, and it slowly got better over a period of weeks. Taking that as a lesson learned, I slowly hydrated to await the first time. Sadly the effect this time was the opposite. 10 minutes later I had an EXTREME URGE to pee and did not quite make the 5 steps to the toilet. Very ugly. And after the mop-up I had another urge that resulted in a small amount of fecal matter (poop), soft from the high fiber content. I guessed maybe the poop was what pushed on the bladder causing my accident, but 15 minutes later the same thing happened again with the urine, only worse. So instead of the feared stoppage, I was dealing with total incontinence.

I used some old underwear to “diaper up” in my briefs and did some quick internet research. Apparently the only cure for post-catheter incontinence is time and muscle discipline. Knowing that muscle discipline is at least 50% mental, I resolved to fight the urge NO MATTER WHAT. This approach made the next episode slightly better, and each following episode improved dramatically. There were issues with extra dribbles after, but these improved as well. By 11PM Friday night I was able to wear shorts again and make it to the bathroom without urinary mishap. Slept one six hour stretch that night with no problems. Any amount of waiting and moving around after the initial urge was a recipe for pre-leakage (but not disaster), even Saturday evening 24 hours later! Still improving as of this writing.

Poop

Since the GI system had such a poor start, I employed two strategies to get things going. Took a full 4 oz. dose of Milk of Magnesia (MOM) Friday morning, then had oatmeal for breakfast, soup and toast for lunch, and a turkey pot pie for dinner. Then half a dose of MOM before bed. Had one other small, soft movement on Friday, then nothing. But all day Saturday things have been liquid, and potential gas events could not be trusted. In retrospect priming the pump with fiber (on Tuesday) was a good move, and resuming normal eating cycle was all that would have been necessary. The MOM just added a day of discomfort. Live and learn! Repeated the Friday meals again on Saturday, and hoping things solidify again on Sunday…

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