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^{Chapter VII. The Hospital Stay}

In spite of its categorization as “ambulatory surgery,” I was not asked to go home immediately after the operation. I found myself in a semi-drugged state, in the recovery area. There, well-trained nurses closely monitor patients’ vital signs. Effects of anesthesia are wearing off, patients are breathing on their own, and tubes are being removed here and there. There is a high level of activity, yet it is smooth and confident. I got the feeling that these people knew what they were doing and did their jobs very well. After all, I woke up and everything seemed to be functional.

I feel great!

I rapidly shook off the fog of anesthesia. Having opted for the epidural anesthetic, this was easier for me than if I had had general anesthesia. The first things I recall were my name being called and a tube being wrestled from my nose. I could hear my friend Margie talking to Nurse Wade. When I became fully aware of where I was and all the surrounding implications, I was immediately anxious to know how an artificial hip joint would feel. Without thinking too much about particulars, I took inventory. I felt great. There was no pain from surgery and the great, gnawing pain of the bad joint was gone, too! This was going to be great!

My throat was sore and my mouth was dry, both effects of the endotracheal tube that is placed in there by the anesthesiologist to assist with breathing during surgery. Recovery room personnel will have ice chips available to suck on, which will temporarily alleviate the soreness and dryness. I took advantage of that as often as I felt I needed to. When one’s comfort is involved, it pays to be assertive. Recovery room personnel are there to get you through the rough spots as comfortably as possible. They will usually go out of their way to help you.

The sore throat and residual anesthesia notwithstanding, I already felt that much had been accomplished. I had cleared all the obstacles in my path leading up to surgery. The surgery had been completed uneventfully. There was no pain from either the bad joint or the surgery, and there was no feeling of a foreign object inside me. I knew, of course, that the surgery was the easy part—I just lay there passively while the surgical team did all the work—and that rehab would be grueling, lengthy, and difficult. Nevertheless, there was a clearly visible light at the end of the tunnel.

Not so fast, Buddy!

As I further regained my capabilities for acute reasoning, I told myself to temper my euphoria about the lack of pain. After all, the epidural catheter was still installed, thereby effectively blocking any pain I might have had. Still, it was great to be devoid of that deep, ugly, overriding pain I had suffered for years and years. Self-administered epidurals are not a possibility or there would be broad-scale addiction by pain sufferers!

Anyway, I lay there in the recovery room, gradually coming back up to speed, chatting off and on with Margie and Nurse Wade. I was stable for a few hours, so what was the holdup? It turned out that a bed was not yet available. I wanted to get into a room so I could get some sleep. Hospitals must play a continual juggling act with beds. Patients come, patients leave, patients move from one area to another. There never seem to be enough beds to go around. I had been waiting for a room for four hours. One problem, I suppose, was that I had requested a private room, one of which would not be available for another few hours. I agreed to be moved to a semi-private room temporarily until my private room became available, even though this would mean being transferred from stretcher to bed one extra time—and the last thing I wanted at that point was to be moved around a lot.

Coming out of surgery, one lies amidst a tangle of tubes, wires, and various other devices. You will have at least one intravenous (IV) connection, and possibly a spare. Your epidural catheter will still be in place, if you opted for the epidural anesthetic. If you have been given a “pain button,” known as patient controlled analgesia (PCA), it will be dangling somewhere. There might be drains coming from your surgical incision. A Foley catheter will have been inserted into your bladder and connected via a tube to a reservoir beneath the stretcher. You will have an oxygen cannula in your nose. You might have a blood pressure/pulse monitor attached to you, as well as a blood oxygen concentration sensor clipped to one of your fingers. Having had a hip replacement, you will have a couple of other mechanical devices specific to this type of surgery. One will be a pair of inflatable leggings, secured by Velcro straps, which are attached to a compressed air supply and a sequencer that alternately inflates and deflates the bladder in each legging. The purpose of this device is to prevent deep vein thromboses (DVTs), which are clots caused by blood pooling in the inactive legs. These are dangerous, as they can break away and lodge in the lungs, becoming potentially fatal pulmonary embolisms. Prevention of DVTs is part of the reason you will find yourself wearing elastic, thigh-high compression stockings on both legs after surgery. These are also effective in reducing post-surgery swelling. Finally, you will have a large, foam rubber, wedge shaped abduction pillow (sometimes called an abduction splint) strapped between your legs to guard against dislocation of the newly installed joint. Is it any wonder why I wanted to avoid being moved too many times?

I was moved to my first, semi-private room uneventfully. I had no roommate. I think at that point that I must have dozed off. I had said goodnight to Margie and the rest was fuzzy until I responded to a knock on my door at about 1:30 AM. “My name is Vickie. I’m your night shift nurse. This is Nate. We’re here to move you to a private room.” Nate was a large man, perhaps 6’5”, 350 lb.—NFL offensive lineman size. However, he was very gentle for his size. This would not be my last encounter with Nate, but it would turn out to be much more pleasant than the next one. Fearing all sorts of post-surgery problems and feeling very fragile, I probably resisted moving, but in his convincingly insistent way, Nate got me moved.

In my own room, I found that it was difficult to sleep. I am not a back sleeper, but from this night forward for at least six weeks, I would be required to sleep on my back. There was no tossing and turning, given that the abduction pillow anchored my lower body. The air compressor that inflated the pneumatic leggings periodically was noisy. I did not get much sleep the first night after surgery. Overall, however, I was comfortable. I did not have to worry about voiding my bladder, because I still had the Foley catheter. I had no pain, because I still had the epidural and the PCA. It was dark and quiet and that was nice.

Day Two: the best of times and the worst of times

Morning came early, as it usually does in a hospital. The first wave, at 5:30 AM, was the vitals person, who comes in to take blood pressure, pulse, and body temperature. Then, the nurse arrived with my medications. Recall that I had advised you to bring your own routine medications, such as blood pressure pills you might be taking, because it is generally much cheaper to use your own than to buy them from the hospital pharmacy. Well, either no one wrote, “Patient uses own meds” on my chart or no one read it. This was the essence of my first controversy; however, it was quickly resolved. The nurse quickly recognized the error, taking my drugs to the pharmacist, who examined them to be certain they were correct, then returning them to me. Subsequently, I was able to take my own drugs, but I would frequently have the same discussion when a new nurse did not read the chart. It became a comedy routine, as I would wait to see how it was handled each time. When I get the final hospital bill, I will be on the lookout for duplicate charges for drugs I supplied myself!

The next wave of troops through my room was the surgical residents. They examined the incision and changed the dressing, asked me how I was feeling, exhorted me to use the incentive spirometer to keep my lungs active and clear, and went on about their rounds. Yes, it was that quick.

Getting out of bed

Day Two would be a busy one. I knew that I would be getting out of bed and I had no idea what to expect when that time came. The nurses fitted an overhead trapeze to my bed, which I would be using when it was time for the physical therapists to get me out of bed. I remember thinking of how it would feel to get out of bed at that point. My left (operated) leg felt like it was made of lead. It did not seem to want to move very easily at all. Still, I knew that it would move when it was time, and the time would come soon.

The physical therapists, Gene and Charlie, arrived in mid-morning. The first thing they asked me to do was recite the precautions to protect the new joint against dislocation. For a total hip arthroplasty using the posterior-lateral incision (the most common approach), they are:

• Do not bend the hip more than 70 degrees the first two weeks and 90 degrees thereafter. (This varies from surgeon to surgeon, but 90 degrees is common for the first six to eight weeks.)
• Do not rotate the operated leg inward.
• Do not cross the legs or move the operated leg across the central axis of the body.

I would be asked to repeat the recitation of these precautions each subsequent time a physical therapist came to see me. Some of the nurses also quizzed me on the subject. Clearly, they wanted to be certain I did not dislocate the new joint.

Charlie started me moving with some simple ankle pump exercises, which gave me confidence in the notion that at least my feet were still functional. A couple more standard, supine, in-bed exercises—quad and glute tensing—were next. Then, he unhooked me from several of the devices and helped me to a seated position at the edge of the bed. This was a great effort, and by the time I had completed it, I needed a minute or so to rest before I was ready to try to stand up. Gene had positioned a walker in front of me, and he instructed me in how to use my arms and my good leg to push myself off the bed. (This was a completely natural motion for me by that time, because I had practiced it ever since I had the pre-op visit from Bruce.) I was up and supporting myself with my good leg and my arms via the walker!

A little stroll

Gene asked me if I felt like taking a walk. I said, “Hell, yeah!” He asked Charlie to fetch another gown to cover my backside, as we were going to be in the public hallway. I told them that I did not mind people gazing at my naked butt. Gene joked that it was probably for their protection. Now that I was properly sheathed, Gene would show me how to walk. I had practiced this before, too, but it is a little harder doing it the day after surgery. My first goal was to get out the door of my room, across the hall to the nurses’ station, and back. It went slowly, but my prior practice helped me get up a good rhythm. I walked to the end of the nurses’ station and rested. I could hear Margie exclaiming “Amazing!” and I guess it was amazing. Dr. G stopped by to ask how things were going and if I had any questions. I told him that the biggest question at that point would be whether I would have the energy to get back to my room! I was being somewhat facetious but still I was starting to feel fatigued. Slowly, I made my way back to the room, with Gene and Charlie at my sides. They helped me to sit down in the chair. I felt exhausted, and a bit lightheaded and nauseous. I asked Margie to get my oxygen cannula back on. That helped a little bit. I was still not feeling very well, and I was sort of nodding off. This was hard work!

Extubations

Everything was hooked back up to me and I was left alone for a while. The nurse, Jill, told me to buzz her if I needed anything. She told me that sometime soon, the “pain team” would send somebody to remove my epidural catheter, and then within a few hours thereafter, she would remove my Foley catheter. (Quite a convenience, that thing!) All went well when the time came. I was issued a calibrated plastic hospital urinal and a couple of stylish bedpans, and was instructed to use them to relieve myself.

The “pain team” arrived in the form of an anesthesiology resident. I was still sitting in the large, comfortable chair, relaxing after my heavy exercise. The pain team asked me to lean forward so he could pull out my epidural catheter. I balked at that, thinking once again of all the precautions I had been taught in my reading, in Bruce’s visit to my home and by the hospital physical therapists. I was not supposed to be bending the hip joint more than 70 degrees for the first two weeks. Therefore, I told the pain team to go fetch a physical therapist to supervise this operation. He was not pleased. However, I did not feel comfortable doing something I had been cautioned about repeatedly. When Gene arrived and positioned me properly, it took the pain team about five seconds to remove the epidural catheter. I could not even feel it coming out. There was no pain whatsoever. The pain team was finished, no doubt quietly celebrating the fact that they would not have to visit this finicky patient again.

The afternoon physical therapy session was uneventful. Of course, I was asked to recite the hip precautions. I walked a bit farther, got fatigued, and this time came straight back to bed instead of using the chair. The oxygen was once again a welcome thing as was the ice water on the bedside tray. I was exhausted. I decided to take a little nap.

Next, Jill arrived with an ominous looking plastic thing, stating that it was time to get rid of my Foley catheter. She said I was fortunate that I was on a urology floor, because all the needed equipment was there. She closed the curtain around my bed and quickly went to work. Once again, I had no fear. I had a Foley 17 years before, after abdominal surgery. Jill knew what she was doing. Asking me to take a deep breath, she yanked the hose out of me before I even knew it.

What goes in must come out

Now, this is where the problems started. The evening shift nurse, Mike, told me that sometimes after removing a Foley, people could not seem to urinate for a while, partly due to residual effects of the anesthesia or due to irritation by the catheter itself. He further stated that if I could not show reasonable progress toward voiding normally by the end of his shift, he would have to do another catheter. This could be viewed as either a major incentive to urinate normally or a major psychological block against it! (Try not to think about elephants sometime.) As time passed, I got the feeling that nothing was going to happen.

Earlier, I had been feeling weak, with elevated pulse rate, elevated body temperature, and signs of anemia. Margie, who I will reiterate is a friend of mine who is also a physician, examined my chart with my permission and, noting that I had lost 650 cc of blood during the surgery, inquired about the possibility of transfusing the two units of my own blood that I had given prior to surgery. Nurse Mike agreed to call the doctor about doing that. It took quite a while to get clearance. Eventually, a very pretty young woman arrived from the blood bank with the first unit of my blood. Mike connected the appropriate tubing to begin my transfusion. (I felt better immediately, for I had paid $35 to have the blood shipped from the Blood Bank in Orlando up to Gainesville, and later I would discover that I paid another $400 to have the blood stored and processed at the hospital!)

Meanwhile, back at my bladder, things were not going well. I was able to dribble out only a little at a time. By an hour or so from the end of Mike’s shift, straining and concentrating, I had only managed to produce about 300 cc. Mike made a deal. If I could get another 100 cc by the end of his shift, he would not give me the dreaded catheter.

Looking at my I.V. rig, there was the blood and a big bag of saline solution dripping rapidly into me. I knew that I was taking on a significant volume of fluids. Even if I eliminated another 100 cc in an hour, my bladder would be filling. Still, being a consummate competitor, I was able to produce the 100 cc and send Mike home without the need to catheterize me. As it turned out, I was only kidding myself.

My competitive spirit came back to haunt me. I knew that before the night was over, I would have to be able to do something about this problem. Vickie, the night nurse obtained the second unit of blood, hooked it up to the I.V. and it began dripping directly into my beleaguered bladder (or so it seemed). Later, she came by to check on me and noted that I had met my goal with Mike, but how were things going along those lines? I told her not so well. She told me that she would have an aide, Bobbie, do a bladder scan to see how full it really was. I told her that she would find it was up to about my back molars. Well, the bladder scan machine’s batteries were in need of charging and Bobbie could not figure out how to plug it into an AC outlet, so rather than fool around with that, I said, “Bobbie, I don’t need a machine to tell me that my bladder is about as full as it could get (and I have a legendary beer bladder). I can’t seem to do anything about it, so let’s get that catheter.” Ever helpful and considerate, Bobbie said she would ask Nate to do it, “because men usually did not want women doing that to them.” I said, “Oh, that’s alright. I really don’t care who does it as long as I get some relief.” However, Bobbie was already on her way out the door in search of Big Nate.

It seemed like forever before Nate showed up with the catheter. I can only recall one time, after a beer party, that I ever seemed that full. I was at Nate’s mercy. Fortunately, for a huge man, Nate was gentle and efficient when it counted. When he was done, he showed me a container, telling me that he had drained 1275 cc out of me. Apparently, though, it was not a record, not even on that floor of Shands Hospital. Someone else the previous week had amazingly produced 1900 cc! So much for my competitive spirit! The main thing was that I felt so much better. Moreover, after that, I was able to empty my bladder normally and completely.

Day Two drew to a very late close. I got only a few hours sleep.

Day Three: the march toward self-sufficiency

I was feeling much better. I felt that I was “over the hump” with respect to post-surgery recovery. I was still constipated from the painkillers, but that would resolve in time. (I will not go into graphic details here.) I was actually looking forward to physical therapy and to spontaneously getting out of bed whenever I pleased. The morning of Day Three began as usual, but things were a little looser because it was the weekend. The residents showed up closer to mid-morning than to dawn, and there was a somewhat new cast of nursing characters. Twelve-hour shifts were standard for nurses on weekend shifts. That is not good for either the nurse or the patient. I noticed that the responses to the call button were generally very slow on Saturday and Sunday.

My was too warm. This is unusual, in that hospitals always seem to be chilly. Well, I like it cool. The attempts by hospital personnel to crank down the thermostat in my room did not yield the desired effect. It was set at 60, but the room felt more like 80. I asked the nurses if they had a portable fan somewhere that I could borrow. They did not. Margie to the rescue! She volunteered to make a short trip to a local Wal-Mart for a fan. It turned out to be a wonderful fan for several reasons. First, it cooled me down. Second, its white noise drowned out the annoyingly intermittent sound of the air compressor for my leggings, allowing me to sleep more easily. Finally, it will continue to give others similar pleasure, for I donated it to the Seventh Floor when I left!

I had decided that I would set some of my own goals and hold myself to a higher level of post-surgery achievement and mobility than was usual for the hospital. After all, I was younger than most people who undergo this surgery, and presumably could perform better. One thing I insisted upon was that the bedside urinal be moved to the bathroom, so I would have to get my butt out of bed at least as often as I needed to urinate. This would require a little coordination with the nurses, because someone would still have to unhook me from the “leg squeezers” in order for me to get up. When I was done in the bathroom, someone would have to re-hook me up. The inconvenience was not a deterrent. I eschewed offers of help to get out of bed. I wanted to do it all on my own. Instead of being supplied with a washbasin and some washcloths at bedside for my bathing, I asked that towels, washcloths, soap, and so forth be supplied to the bathroom, where I would do my own sponge baths standing up. I requested that a “commode chair” of the proper height be installed over the toilet so that when my bowels began functioning normally again, I would go to the toilet without violating the motion restrictions instead of using a bedpan. I was anxious to get things going.

Other than the twice-daily comedy involving nobody reading my chart to see that I had brought my own medications, the hospital stay proceeded unremarkably apace. Physical therapy became a routine, twice-a-day, ever lengthening walk around the floor with the aid of a walker at first and then, later, crutches. I was feeling good about my progress and I started wondering about when I could leave.

How long will I be here?

I was told in my pre-surgery briefings that I would be in the hospital between four and five days, and I would have to meet certain milestones before I could be discharged. Having read that in other countries people having the total hip replacement operation are hospitalized from 10-14 days, I had wondered if this was not cutting things just a little close. However, after three days in the hospital, having made significant progress, I knew that four or five days were probably going to be sufficient. I was feeling good, and I was feeling that I could do many things on my own already. Furthermore, I would be transferring to an in-patient rehab hospital for a while before going home. My target became four days.

Your surgeon will be keeping an eye on you by way of personal visits and the reports from the nurses, who are the front line troops waging the battle for your health. You will be expected to have regained some mobility with the operated leg before you can leave for either an in-patient rehab or home. Physical therapists will make careful notes about your progress. The nurses and doctors will also monitor your overall health. Before you are discharged, all systems will have to be functioning well.

Walking milestones

You should be able to walk with the aid of a walker or crutches. If you have stairs in your house, you should have been able to walk up and down a flight of stairs. You should be able to do some limited tasks while standing. If you will be going to a rehab facility, which is advisable if you live alone, you will learn many more techniques. It is the hospital’s job to get you past the acute care period. Either you or the rehab must take over from there.

Medical milestones

You will be kept in the hospital until it is clear that you have no complications from the surgery. These would include infections, deep vein thromboses, lung problems, and problems with the actual prosthesis.

Where do I go from here?

Generally, you would go either to a rehab or directly to your home after your successful hospital stay. In my case, because I live alone, a rehab was recommended. There, I would continue physical therapy, and I would receive occupational therapy as well. I had discussed the rehab option with various people in advance of the surgery and the feeling was that I would be spending from seven days to two weeks in the rehab. Those of you who have a spouse or significant other or a hearty volunteer living with you might opt to go straight home. It is a matter to be decided upon after consultations with your surgeon, other trusted medical advisers, physical therapists, and your family.

Days Four and Five: the waiting game

While my goal was for a four-day stay, a slight hitch caused me to extend to five days. This had nothing to do with walking milestones or medical milestones. It had to do with no bed being available for me at the rehab hospital to which I was being transferred. I had been making significant progress with my physical therapy sessions, walking for relatively longer distances every day. I would still be tired after walking completely around the floor, but I was feeling stronger. I was using crutches as well as the walker. I was not very hungry, but the hospital food was nevertheless beginning to get on my nerves. Margie was gone, so I was lacking company. I was bored. Days four and five were spent playing the waiting game, accomplishing little but some extended TV watching and working toward getting that bed at the rehab.

During the planning period, I pondered the issue of how I would be transported from the hospital to the rehab about a two-hour drive. My options were either a private car or a non-emergency medical transport. I had been warned by the people at the rehab that it was a long ride in a passenger car for a new hip replacement. They recommended the medical transport. However, having practiced getting into and out of my personal car with Bruce, the physical therapist who visited my house, I was well aware that I could do so without great problems. As for the two-hour drive, I reasoned that I would be in a reclined position for two hours with my legs stretched out in front of me, which was the position in which I spent most of my hospital time. My car has a nice, wide door opening, and the passenger seat not only moves rearward a fair distance but also can be made almost completely horizontal. Therefore, my executive decision was that I would have a friend drive my car up to Gainesville, pick me up, and drive me to the rehab.

When the time came, I instructed my friend in how I would need to have the car arranged in order for me to get into it properly. I had grabbed a physical therapist from the hospital just to have a little skilled help around if I needed it. It turned out that I did not need it. Once the car was properly arranged, (which it would have been already if anybody had listened to me in the first place), I slipped into there just like a hot knife through butter.

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