MEDEVAC V – Surgery

Friday 10 August 2007
1615

I had my surgery on Wednesday, and am now on “quarters” for five days. That means I am supposed to stay in my room in bed and not go anywhere or do anything. It’s now Friday and I’m feeling better, so I plan to slip out and get on the internet sometime later today. I wish they had a connection here but they don’t so that’s my only choice. I am writing some offline emails as well as this entry, will rest some more, and then go over sometime after lunch.

I know that I said I was not going to go into detail about my medical condition or my surgery, but I changed my mind. It was pretty cool, and I want to write about it. So if you are squeamish or just not interested in details, stop reading here. The rest is about the condition and the procedure.

First of all a word about my medical condition. I said earlier that it was hereditary and needed to be taken care of, but was not extremely serious or life-threatening. It is also not very romantic or heroic – varicose veins. I have had varicose veins in my legs for some time. My left was worse than my right. They were pretty unsightly but they never gave me much trouble. A few years ago they did start to burn and itch from time to time, but I started taking a nutritional supplement (Horse Chestnut Extract) which alleviated those symptoms very effectively.

There were a couple of spots that were getting to the point where I was thinking I’d have to have something done. I remember while backpacking with some Boy Scouts that I banged my left leg on a rock or a tree or something and it really hurt. I thought at the time that if it had started bleeding I might have had a problem. But I didn’t have medical insurance and just procrastinated.

They really didn’t bother me or interfere with anything, even doing PT. I am in good shape and passed my PT tests with no problem, although I don’t run on a regular basis – I walk instead. This is more to make sure I have knees and can still bike and backpack when I’m 70 than for anything else.

On the way home for R&R leave in May, they finally did cause me a problem, although I didn’t know it at the time. On the flight, I developed a pain in my left lower leg and a big lump above my combat boot. I had not loosened my boots for the flight, and I just thought it was a muscle cramp. It turned out to be a blood clot in one of the varicose veins on the back of my left leg. It really felt like a pulled muscle, and I treated it as such, massaging it and applying topical analgesics. It went away and stopped hurting after a couple weeks. I didn’t find out it was a blood clot until later.

Then in early July, back in Kuwait, I woke up with another blood clot. This one was different than the first one. It was on the inside of my left calf near the shinbone, right in a place where there had been a prominent varicose vein. It was red, swollen, and tender, and hurt so badly that I could not put weight on my leg when I first got out of bed. That alarmed me quite a bit. I hobbled around and got ready for work, and it felt better as the day went on. But when it was just the same the next morning, I went to the TMC right away.

Being a Sunday morning, the TMC was lightly staffed so I had to wait awhile. I also had to go through their process, as you might imagine from reading my earlier entries. After seeing a couple different people and bouncing around a bit between the TMC and the hospital, they gave me some support stockings and made me an appointment for an ultrasound examination downtown.

The ultrasound examination was pretty cool. They ran the sensor up and down my legs, looking and listening. They did tests of my circulation by squeezing my legs in various places. The resulting information was that I had two blood clots as described earlier. The first one no longer hurt, but was more of a hardened lump. The second was still quite painful and tender. The other result was that they told me I had a lot of “reflux” in my superficial veins. This is basically backflow through the valves. (As you probably know, the veins in your legs have a number of one-way valves to hold the blood from flowing back downward in between heart contractions). As you age, the valves get less efficient. In varicose veins they have no supporting muscle tissue around them and so the veins bulge, the valves can’t hold back the blood, and you get reflux. It was very strange to listen to the squishing noises as my blood flowed backwards when they squeezed. It was also disconcerting – I have always been in good health and it is not a comfortable feeling to be so immediately aware of malfunctions in your own system.

What causes the blood clots is the blood pooling in the varicose veins. Since the circulation has become inefficient, there are places where it just sits there instead of moving, and that’s how the clots form. In deep veins this is a very dangerous condition because it can cause strokes, heart attacks, or other embolisms. They assured me that my deep veins were very healthy, that this condition was not really a problem with varicose veins, and that the risk of complications was very, very low. Nonetheless, it needed to be treated.

So that is the condition that this whole trip was all about. I’ve already written about the rest of the MEDEVAC, although I don’t think I mentioned that I had to learn to give myself shots in order to administer blood thinning medication. They had me on this between Kuwait and Fort Benning. When I got here the doctor told me to stop taking it, and I gladly complied.

My surgery took place at Eisenhower Army Medical Center at Fort Gordon, GA, about 3-4 hours from Fort Benning, near Augusta. Someone from the unit drove me over in a car. We left at 0500 and got there just after 0900. My appointment wasn’t until 1000, but when I got there they didn’t waste any time – they got right to work. This was the first time I had ever gotten to an Army medical facility where they didn’t hand me a clipboard and ask me to fill out paperwork. They just asked for my ID, looked me up in the computer, and said “OK, here is a gown, go strip from the waist down and put it on”. Halleluiah! That is the way it ought to work everywhere.

They got me up on a table and the ultrasound technician and nurses/PA’s got busy prepping me. The first thing they said was “Wow, are your legs ever messed up!” I thought “well, thanks for saying so”. Then the ultrasound tech said “Man you are going to bleed a lot today! You are going to be one hurting puppy when we are done”. I was a bit surprised by this. I asked her if it was her job to try to scare me off, and she said “No, just being realistic.” Hmmmm. I’m glad I’m not squeamish, because I think that would have alarmed some people to the point of having a negative effect.

Another thing that took my by surprise, in a positive way, was when they asked me what music I liked. I wasn’t prepared for this! I asked her what they had, and she said they had a lot of stuff. I told her I had my iPod, and she asked me to give it to her. She took it and hooked it up to their system and we listened to my music as they did their work. At first she just set it on “all” but when some raucous rock music came on I suggested Franz Danzi instead. So she set it to play all my Franz Danzi music and the rest of the morning was set to Bassoon Concertos and Woodwind Quintets. Not only was this more relaxing to me, but I thought it was a better working environment for the doctors and nurses than Alvin Lee (which probably contributed quite a bit towards my own relaxation!).

They marked up the varicosities with a Sharpie, got me on my back, and got my legs all sterilized with iodine. The ultrasound technician checked me out again to ensure they had a clear picture, and in came the surgeon. There was also another doctor with him assisting. The doctor had discussed in advance with me what he planned to do. Here is a website that explains it in some detail – watch the “Patient Education Video”: www.venacure.com

The marketing materials say that this is not “surgery”, but is rather just a “clinical procedure”. I think that is splitting hairs. It may be minimally invasive, and it may not require hospitalization. But whatever you call it, and regardless of how small the incisions are, it is still invasive and I call it surgery.

He had explained that he would use only local anesthetics, not a general, so I would be fully conscious the entire time. They had asked me on several different occasions whether this was ok. I finally convinced them on the operating table, when they asked yet again. I pointed to the scar on my left knee and told them that was where I had given myself stitches while backpacking. If I can give myself stitches with a tent repair kit and no anesthetic, I think I can handle letting professional doctors work on me in a modern operating room under a local. :-)

In addition to the injections of local anesthetic up and down the leg, they also used something called “tumescent anesthetic”. This was a saline solution containing lidocaine, which they injected in quantity around the entire length of the main vein, creating a buffer of fluid all around it. This was not only to further numb the vein and tissue, but also acted as a heat sink for the laser to prevent it from burning the surrounding tissue.

They got started, and it was a treat to listen (and to some extent watch) them work. They were a well-drilled team, and worked well together. The doctor called for the various tools (mostly endoscopic catheters, wires, tips, etc) and then inserted them in and did his work. Each time he was going to stick me or cut me he’d say “little prick”, or “prick and a burn”, or “this will create a full feeling”. It was quite reassuring and usually felt exactly as he’d described. The main incision was below my knee, through which they inserted the various tools upwards towards my groin. Although I was numb to pain, I could feel them going through my veins by the pressure and tugging they exerted on other nearby tissues, and even a sort of attenuated sensation from inside the vein itself, although this might have been imaginary.

The ultrasound technician was an integral part of the operation, since she was the surgeon’s eyes into the veins. She kept her sensor located right over where he was working, and he would periodically verify his position with her, specifically in relation to intersections with other veins, etc. It was pretty cool.

They had me slightly head down on the table to keep the blood flow minimized, so I couldn’t really see anything. Frankly it was just as well, because as things progressed I could tell from the wet feeling that there was quite a lot of blood and other stuff down there. But I’m getting ahead of myself.

When it was time to activate the laser, he went through a drill to clear the room of anyone not wearing laser protective glasses. They put glasses on me as well, and then they started the machine. Apparently they have some sort of scale to measure and track the position of the laser. I am guessing that they were counting in millimeters starting at the top of the vein. The doctor would say a number, and a technician at the laser would verify when they reached that point. It reminded me a lot of LASIK (for good reason I suppose!). A few moments after they got started, I had an interesting sensation – the smell of burning flesh. It was faint and intermittent, but unmistakable. I guess it must have escaped out of the incision at the base of the wire – the burning must produce some gases.

That part lasted awhile, but was not the most time-consuming part of the procedure. What the patient education video didn’t discuss was what they do *after* they are done with the laser. I was under the impression that they would collapse the veins and then that would be it – they would somehow be reabsorbed into my body or something. WRONG!

Most of the “prick and a burn” sensations I was feeling earlier were all the local anesthetics they were giving me around the sites of the peripheral varicose veins branching off of the main one they collapsed with the laser. They apparently tied these off and severed them. Then they pulled them out.

That’s right – pulled them out. Ripped ‘em out by the roots. Not only that, they also pulled out the main vein they had collapsed. That was a *very* strange sensation. I could feel not only the peripheral pulling and tugging, but also the sliding as the main vein slipped out of my leg. Kind of like your lips feel when you suck a strand of spaghetti into your mouth, except all up and down the inside of my leg. Bbbbrrrrr! It was a little creepy.

When the head surgeon had done the main vein on my right leg, he switched to my left and did the laser procedure there while his assistant finished pulling out the peripheral veins on the right leg. I could tell that this doctor was less experienced. I never felt any pain at all when the head surgeon did his thing, but several times had to ask for more anesthetic on my right where the assistant was working. I just don’t think he had the experience to know exactly where a vein he was pulling on was connected, where it was going to hurt, and where to make the injection to numb it properly.

I tried not to be a pussy about it (I even said once to him “I don’t want to be a wuss, but I think maybe some more anesthetic would be in order”). Another time I even flinched a little and said “Whatever you are pulling on is still connected someplace!”

It was weird – the veins are very elastic, and so when they pull them out they have little pliers or clamps or something, and you can feel the stretchiness (like a big rubber band or the surgical tubing on a slingshot) as they pull on it. It begins to give way, and then finally lets loose and slides out. They did this over and over – I think there must be about 10-15 incisions on each leg. I could hear the “plop” as they would drop pieces of vein into the pool of blood on the table between my legs. Part of me wanted to sit up and look, and part of me didn’t really want to see. I decided to wait and ask them afterwards if I could see the veins, but by the time they were done I was kind of exhausted and I forgot to ask.

The entire procedure lasted about two hours, and being conscious the entire time was exhausting. I knew I needed to relax, and tried very hard to just relax my legs (and my whole self). But lying in one position not moving is hard, and there were times when it really felt like I *needed* to move my leg. I could feel my muscles tensing, and I would just take a deep breath and relax. It helped to move my arms and to flex my hands. It also helped a lot to listen past the operating room chatter and concentrate on my music.

And there was operating room chatter! I always used to think the chatter on the show M*A*S*H* was just Hollywood, but it was just like that. It was actually kind of funny. They were just professionals going about their routine jobs, and although they focused their communication quite intently at the critical points, at other points they seemed very relaxed and were talking about their kids, who was dating whom, giving one of the nurses grief about her boyfriend, etc. It might sound like that would be disturbing (“Pay attention to my leg, dammit!”), but actually it was very reassuring. They knew what they were doing and they were relaxed, and that helped me to relax.

My left leg was in much worse shape than my right. There was a huge bulge below my right knee where there was just a honeycomb of varicose veins. This was the place I was most concerned about while backpacking because it just felt weak and exposed. Before this procedure I would feel pressure there whenever I sneezed or blew my nose – it almost felt like it was blowing up like a balloon. After pulling out the main vein in my left leg, the head surgeon went to work on this area. It took him quite awhile. I don’t know how many of the veins he actually pulled out and how many he just tied off, but it hurts a lot so I think he probably pulled most of them out.

Finally he stepped back and said “There, we’re done”. I sort of half sat up and looked down at my legs and I noticed that the blood clot was still there on my calf. I asked him about it and he said “Oh, we don’t worry about that – it will resorb”. This seemed a bit strange to me, since that was what was causing the pain and was the whole reason I had come in the first place, and I told him so. He said “OK, I guess we can evacuate it”, and set to work. So they took out the clot. That area has wound up being the most painful during my recovery so far – maybe I should not have said anything!

They ended up only doing the main front veins, which were by far the worst. The rear veins (actually I think they might be called superior and inferior, but perhaps anterior and posterior – I’m not sure) were not nearly as bad. He asked if I had trouble with them and I said not really. He felt that doing them would be an awful lot of surgery on one person in one day. My preference would have been to just get it all done, but he didn’t think it was necessary so he didn’t do them. As a matter of fact, the first clot is still in there – he said it would be resorbed with no trouble.

After that the doctor left and the nurses cleaned me up and dressed my legs. The incisions were so small that they didn’t close them up – just a small piece of surgical tape over some of them. They packed them with gauze pads (lots of gauze!), and wrapped my legs with gauze rolls. Then they wrapped over that with Ace bandages, *very* tightly. Then they told me I could get up and get dressed.

I was a bit shaky, and it was hard to move my legs. With the bandages they didn’t bend very well. But I got dressed, and then went to the pharmacy to get my prescription (Percocet for pain). They put me on five days’ quarters and then a thirty day convalescent leave after that. I had some lunch, and then called my ride and we left for Fort Benning.

The ride back was not too bad. They had given us a small car, so I sat in the back seat, with the front seat all the way forward and my feet propped up on it. I had the sergeant stop at the PX on the way in so I could pick up some more milk and other things I would need for five days in my quarters.

They have a mess hall here but I haven’t been eating at it much. I’ve been having cereal for breakfast in my quarters, and also just making a sandwich for lunch. I have had dinner over there a few times but it’s hardly worth the time to wait for a ride. So more often I’ve been buying something at the internet place. Last night I actually had them bring me dinner from the mess hall (they will do that since I’m on quarters). That worked out pretty well and I’ll probably do it again today.

The first day and night recovering were not very comfortable. I slept with my legs elevated on couch cushions and took the maximum dosage of my pain pills. As the local anesthetic wore off I could really feel where they had gone to town on my legs. The incisions sting a bit, but the worst sensation about them is the feeling of pressure from the inside, like they are going to bust out bleeding again. Two of them bled through my bandages on the way home, but that is not as bad as the nurses had said it would probably be, so I didn’t worry about it.

They told me to keep the dressings on for 24 hours, then remove them and shower (actually to shower and remove them – they said to get them wet first so I didn’t rip off the scabs and open the incisions). So I did that yesterday around noon. It was quite a production. I was well rested, and laid out all the dressings they gave me on the bed before going in. Then I went into the bathroom and took off the outer dressings. I got into the shower and took off the rest, very carefully. Then I washed all over with soap, albeit gently. A couple of the incisions started to bleed again a little, but not much. Most were already well on the way to being healed.

I got out and dried off (I had made sure to do laundry that morning so the towel was clean) and then sat down on a chair in my room to re-wrap my legs. They were still quite painful (despite the meds) and hard to bend. I put band-aids over the incisions to ensure that they stayed closed, then put gauze pads over them. I held those down with pieces of tape, and then wrapped the whole area with the gauze rolls they gave me.

At this point a question I had was answered. I had been sort of surprised that they had not prescribed an antibiotic. I speculated that the philosophy on that has changed due to all the resistant strains of bacteria that have been appearing, and that perhaps they only prescribe antibiotics when you actually have an infection. But whatever the case, they didn’t give me any and I was being *very* careful not to introduce any potential for infection. I felt kind of exposed at that point. But when I looked at the gauze pads and rolls they had given me, I found that the gauze itself is antimicrobial. It is treated with an antimicrobial substance, and so just wrapping my legs in it provides not only a physical barrier to infection but also a chemical one. So now I feel better.

I really didn’t want to use the Ace bandages again so I put the compression stockings on instead. These are like very strong, tight nylons. I had been wearing them since first seeing the doctor in Kuwait just to control the varicose veins, but now they hold on the dressings quite nicely.

When I finished the process of re-wrapping my legs I was surprised to see that I was sweating and felt shaky again. I think the surgery took more out of me than I realized. I have spent the past 48 hours mostly sleeping and resting.

My legs are still quite painful, although they are getting better. The spots inside where the veins used to be feel like pulled muscles when I stand up and stretch. There are a few spots that feel very tender and where I feel pressure if I stand up too long. Now, 24 hours after re-wrapping my legs, they are starting to itch. They didn’t really give me any guidance as to what to do after the first 24 hours, and didn’t give me enough gauze or anything to re-wrap them again. So I think I’ll leave these on another day before I take them off. By then the incisions should be pretty well healed, and if any of them are still touchy I can deal with them individually.

Monday morning I have an appointment for another ultrasound, and then I plan to fly out that afternoon or evening to go home for convalescent leave. I don’t have tickets yet or even know when the flights are. I am so cut off without internet access that I have to wait until I can get over there and look. But it will be sometime late Monday if I can arrange it. That is the unexpected bonus in this whole ordeal – I get to go home and see my kids for a month before returning to theater. :-)

Now for two and a half more days of quarters….blecch.

Mood: Tired
Music: Ideal - Blaue Augen