What To Expect After Elbow Surgery

So back in July, I posted here (link here) that I'd screwed up my olecranon bursa on my left elbow by jamming it tween the arm rest and the fuselage of a 4 hour Delta flight to Cincinnati at Just the Wrong angle.  The bursa ruptured, made my arm swell, heat up (infection), and was painful.  If I tried to load it working out with free weights, working in my yard with hedge clippers, or doing yoga (like plank pose) the elbow was painful, wobbly, and no fun.

Bryce Canyon (not how it is not "smooth")

I took methyl prednisone (at the advice and Rx of an Urgent Care doc here in Carlsbad) to make the swelling go do and relieve the pain.  The steroids worked, But, the insidious damage had already begun on the bone itself, following the bursa rupture.  The bursa fluid provided food for naturally occurring bacteria (like staph) to feast upon, and the bones where it spilled (the ulna, for example) provided an Excellent network of a narrow lattice-like maze where the staph could eat, breed, and hide from white blood cells (lymphocytes) whose job it was to envelope and kill the invading bacteria.  Problem is, the white blood cells are larger than the bacteria, and can't get into all the nooks and crannies of the bone lattice work.

The end of each of the arm bones are supposed top be nice, smooth, elliptical shapes, where bursa and synovial fluid sacs keep the hard bone from rubbing against the other hard bone.  The fluid sacs act as cushions, to prevent bone-on-bone damage.  While working out and going to physical therapy with a damaged bursa, the bones were grinding on each other, the bacteria were multiplying and building infected lairs in the bone, and throughout July and August, it kept getting worse.  Bone erosion, bone infection, bursa inflammation... it was a vicious cycle.

So I go to an orthopedist who does an x-ray.  Being versed in radiography, I know how poor the resolution can be on an x-ray, especially when dealing with 3D shapes, since the x-ray is a 2D picture.  X-rays are also notorious for not being able to see much of anything on low density soft tissue and fluids, aka the inflamed bursa and progressing bone infection.  They prescribe more steroids, and tell me to ice my elbow - with a freezing cold ice bath for 15 minutes being the most effective - and continue physical therapy.

As a good patient, I go to PT three times a week, I ice my elbow at least once a day.  It hurts less, but it is still wobbly, and when I try to do heavy lifting (like 180 lbs bench pressing) or heavy curls (like a 65 lbs curl bar) it screams at me in pain, so I stop.  I can do light hedge clipping, but anything requiring significant effort and strength, the left elbow rejects the notion, completely, sends extreme pain signals to the brain, and I halt the activity.

Throughout August I struggle with this troublesome elbow.  It's not getting better, and it seems to progressively becoming slightly worse.  Yoga poses that use my arms become increasingly painful.  Playing drum set is fine for about 5 minutes, but after that, Ouch, Yikes, Stop!  Dancing (with ethanol enhancement) to silly songs like YMCA or Vogue, where hand movements are necessary Truly Aggravate the left elbow and result in pain, swelling, throbbing... driving the infection (that I did not yet know I had) DEEPER into the bone.

Just before Dr Desert Flower and I went to Montpellier France for a work conference at Labor Day that she needed to attend, the elbow started to get red, swollen, and exude puss (yes, very gross).  I go back to my primary care doctor who looks at it, and categorically says "you need dissection, you need packing, you need drainage and vacuum and antibiotics... you Must see an orthopedic surgeon immediately!"  I told her that all orthopedists were booked for at least the next 6 weeks and I had no way of seeing anyone, especially not 2 days before heading to France.  She leapt into action, and made an appointment with Scripps best elbow surgeon that afternoon.  The surgeon re-arranged his schedule, and saw me late that afternoon in his office down in La Jolla.  He took a culture from the oozing elbow, hoping to grow in a lab whatever the infectious agent that was troubling me.  Nothing grew, of course. He also placed me on a massive dose of broad spectrum oral antibiotics (4x a day), to try and kill (or at least subdue / slow the progress) the infection.

He gave me a huge bag of betadine swabs, sterile gauze, ace bandages with velcro, and medical tape to clean and dress the festering elbow while in France.  I dutifully cleaned my elbow with the betadine swabs each day after I showered, and carefully wrapped it in the sterile gauze for the week we were in France.  On the plane ride home, I sat with my arms crossed over my chest, protecting my sensitive elbow from being bumped by other passengers, the passing drink cart, and anything else in the crammed, lemming-like environment that is the coach economy section of international commercial travel, unless you're on Aeroflot.

When I got back to California, I was supposed to have an MRI of my elbow pre-surgery so that the surgeon would know what to expect.  Due to the arcane and byzantine American health care system, the MRI was Still Not approved by United Health care, and I had to waste a day of my life getting an ultrasound of my elbow, instead.  The Scripps elbow ultrasound radiologist took one look at the high resolution image, and said "this is not classical, you'll be getting an MRI".  He pointed to the screen where the contours of Bryce Canyon were showing up on the end of my ulna, instead of the nice smooth egg-shape that was supposed to be there.  Change the angle of the UT probe, and yep, the canyons and valleys and out-cropping were still there, in graphic 3D.  The MRI should confirm it, the radiologist said.  An hour later, United Health Care approved the MRI, and it was schedule for 2 days later, on a Saturday.

The next day (Friday) the Hospital with the MRI machine called, and said they had a last minute opening, am I available?  Unemployed and unable to use my left arm... sure... I was available.  So I got fast-tracked into the MRI the Friday before my surgery on the next Wednesday.  The elbow continued to "weep" out puss over the weekend and right up to the day of surgery.

Holding the vancomycin "hand grenade"

The morning of the surgery, the surgeon's PA (physician's assistant) comes into the pre-op room where I am wearing just a open-backed gown, and asks me "do you know what to expect, what is coming?"  I told her my abbreviated understanding, of surgery, followed by 2 or 3 weeks to let it heal, followed by weeks or months of physical therapy.  "Not quite" was her reply.  She then laid out the whole treatment plan that I had no clue would be so onerous.

It went as follows:
- Wednesday morning surgery to remove the bursa, and pack in antibiotic "beads"
- the infected bone would be removed (picture a medical dremel tool) to 'clean it up'
- stay in the hospital for 2 days, with my arm immobilized in a cast
- go back into surgery on Friday night, and have the beads removed, check on progress of the wound, clean up anything that needs internal clean up
- Saturday, after surgery, if I am stabilized, go home with a fancy portable vacuum pump, that will keep suction on the elbow wound - which they won't stitch closed - to drain fluid and to aid in the healing and closure of the wound over time
- keep the vacuum pump on me for at least 3 weeks, changing the dressing on the elbow with a visiting home health care nurse 3X a week
- install a PICC line (peripherally inserted central catheter) into my right arm, that runs up to my heart's ventricle vestibule, where it will dump out liquid antibiotics that I will infuse at home, twice a day, for 2 hours each dose, for the next 6 weeks
- come back to the doctor's office once a week through this whole process, to check on progress of the wound healing, to take vital signs, and make sure there's no relapse back into infection.

First look at home, after surgery (disgusting, yes)

Ugh!  I had no idea that it would be such a life-halting inconvenience.  If I had been employed at this time, I would have had to take 1/2 days basically EVERY DAY for a month, to deal with this health issue.  Why could they not just stitch up the elbow, like a "normal surgery"?  Then the bursa would not grow back clean and healthy and the bone infection would continue to destroy the ends of my bones.  It needed to heal "from the inside out", and closing the wound before the bursa had fully rebuilt itself from scratch would have a negative prognosis, with re-infection likely.  According to the surgeon, who volunteers much of his time at the local San Diego VA, Afghan and Iraq vets with bone infections from shrapnel fight the infection for months at a time, on and off antibiotics, and the only way to seriously correct the problem is to surgically dissect (dremel tool / bone saw / etc) the infected bone, and then let the body grow it back.

The surgery went fine.  Two hours under general anesthetic.  The final wound was 50 mm long by 20 mm wide by 10 mm deep (or 2" x 1" x 3/8ths of an inch, roughly).  Bursa removed, and 4 mm of ulna dremel tooled off.  Lots of Percocet in the Hospital to deal with the pain.  The re-check 2 days later also went well, beads removed, I was set to leave the hospital on Saturday with my portal vacuum pump... but.. bureaucracy stepped in the way.  Apparently, no one filed the final paper work to get me a pump to take home, send the vancomycin antibiotic to my house, or arrange the home health care nurse visits.  "We're sorry, but you'll need to stay until Monday, or maybe Tuesday, once the paper work is done."  Unacceptable.

The hospital bed was a VERY uncomfortable "smart bed" made by Hill-Rom Versa Care.  It was supposed to "auto adjust" to the patient laying on it.  Instead, all it did, was inflate and deflate, Every Two Minutes, to tilt my pelvis forward and back, legs up slightly, legs down slightly.  It was uncomfortable, disconcerting, disruptive, and impossible to sleep soundly on it.  Whoever the morons at Hill-Rom were who designed this monstrosity obviously never asked for customer feedback.  The nurses Could Not turn off the auto-adjust, or the bed alarmed at the central nurses' station.  Sleeping on this continually moving, hot-and-sweaty, poorly designed, poorly conceived contraption meant that Saturday night in the hospital was a very unhappy & unpleasant & restless experience for me.

Sunday came, and the bureaucrats in "Program Management" continued to drag their feet.  Apparently walking and chewing gum at the same time was a challenge for them.  "We might have a pump delivered after 7pm tonight, but we can't guarantee it... we don't normally discharge patients on weekends".  UGGGHHHH!  And then "Even if you get the pump, we have not gotten any confirmation that you'll get the antibiotics or wound nurse... so it's best to just wait until Monday or Tuesday."  This was not the Riyadh Saudi Arabia Ritz, and I was not enjoying my house arrest.  But my heroic floor nurse "Jose" leapt into action.  Working 7am to 7pm, he forced the system to accept all the discharge paper work, prepped me for going home, and KNEW that if he didn't get me out before the end of his shift, I'd be stuck in the hospital for Sunday night unnecessarily.  Jose's efforts were successful; the pump arrived at 7pm, we left at 730pm, and the antibiotics showed up on our door step via courier at 1030pm.


Then, everyday, from October 16th through November 22nd, twice a day, I had to sit and infuse my IV antibiotics through my right arm, into my heart.  Each infusion took roughly 2 hours.  I watched all of Stranger Things, Luther, F is For Family, the Twin Peaks Fire Walk With Me debacle, Dr Whos that I had not seen, and re-read Zelazny's Chronicles of Amber, finished JRR Tolkien's Silmarillion, and started Iain M Bank's "Use of Weapons".  I could not sweat during this time, as perspiration caused the adhesives on the PICC line to loosen and come off my skin.  The PICC line ran straight to my heart, and getting a blood or heart infection was not something I wanted to entertain.  So a month of being sedentary was required.  I tried learning basic Spanish in this time too... but without someone to practice and converse with, I made little progress on this front.

Every week I returned to Scripps in La Jolla to have the nurses, PAs, and doctors tell me how "beautiful" my wound looked, and how well it was healing.  Every 2 or 3 or 4 days, I showered with a large plastic sleeve sealed around my left arm, and baggies that looked like a shower cap over the PICC line dressing.  Today (Thanksgiving) was the very first day I could shower and use Two Hands!  Hooray!

First wet to dry dressing, jammed in

During this time, the first 3 weeks, I had to wear the $22,000 portal vacuum pump around my neck (even sleeping with it, and recharging it as I slept).  Every Monday, a nurse came to change out the vacuum sealed dressing.  Every Thursday, I went to doctor's office in La Jolla to have them change it again.  After 3 weeks, the vacuum pump was discontinued, and I had to do a "wet to dry dressing".

What's a "wet to dry dressing" you might ask?  (I had no idea what it was).  Well, using sterile technique with nitrile gloves and sterile gauze and sterile saline, the patient PACKS in sterile gauze that has been wetted in saline, jammed up into the wound, using sterile cotton swabs as well as nitrile gloved fingers.  Yes, this is unpleasant and mildly painful.  Then, the jammed in gauze is covered by a 2x2 gauze pad, which is then covered by a 4x4, which then gets and ace bandage wrapped around it, to hold it all into place.  All of this is done using just one hand, since the left hand is too far away from the let elbow to be of any assistance.  The Next Day, using sterile gloves, all the jammed in gauze is yanked out, and the process started again - approximately every 24 hours.  Each time the nasty used gauze came out, it looked like a little piece of lemon peel.

At my Nov 22nd visit, I was told the "wet to dry dressings" could be discontinued, and "put a bandaid on it" .. a large 2x2 inch bandaid...  but no more dressing changes.  And the PICC line was removed, leaving an irritated upper right arm where all the dressing adhesives were aggravating my fair skin.  Once again, the nurses and doctors admired how "beautiful" the wound was, and how well it was healing, which was a very strange things to experience from the patient's perspective.  I am glad that the whole wound process is NEARLY over.  I go back in 2 weeks for a followup, and THEN likely, physical therapy will begin, and last through MLK day or Valentines day 2018.  I will be happy to begin working out again, able to sweat, and re-building lost muscle mass... as soon as the bursa is re-built.  I Do Not want to re-infect the ulna or any other bones, so I have to take it easy on my arms and lift nothing more than 5 lbs with my left arm until after my next doctor visit in 2 weeks.

My friend Joe M texted me several Spanish curse words, to help me learn the slang of the language (similar to how I first learned French).  If you want to call me up, or text me in Spanish during the next two weeks, I'd appreciate the practice.  In the mean time, I'll be working on legs and core and aerobic exercise, until I get clearance from my doctor to begin rebuilding strength in my left arm.

Yes, this Thanksgiving I am very thankful that my wife has a good job with good health insurance coverage that paid for this 6 digit surgical experience, and I am very thankful I don't have to get my left arm amputated.  One armed drummers are not very good.