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with Rod Moser, PA, PhD

Stories from behind the examining room door, as told by Rod Moser, PA, a primary care physician assistant with more than 35 years of clinical experience.

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Friday, April 1, 2011

Between a Stone and a Hard Place

I had surgery yesterday for the kidney stone that was painfully lodged in my ureter — the tube from my kidney to my bladder. Due to some unexpected and serious ureter swelling and the size of the stone, the surgeon was not able to get it out. She wasn’t even able to get the scope past the obstruction. She did insert a series of stents — devices to widen the narrowed area — so hopefully, she can get it out next time. Next time! It isn’t over for me by a long shot.

The treatment of choice for kidney stones, whether they are in the kidneys or lodged in the mid-ureter, is still lithotripsy — a non-invasive bombarding of the stones with directed sound waves. Lithotripsy pulverizes the stones (hopefully), allowing them to pass. It worked six years ago when I had my first bout. This treatment was not offered to me this time. Apparently, I wouldn’t even be able to pass pulverized stones through my damaged ureter.

We have a large, new and very expensive hospital, but our hospital does not own a lithotripsy unit. Apparently it is leased for one day a month from a company that moves it around from hospital to hospital in a big tractor trailer. All of the patients needing this procedure will get scheduled on this one day per month. Hopefully, the number of people will not exceed the appointment slots, and of course, your kidney stones attack fits their monthly schedule.  I am suspicious that my kidney stone missed the monthly opportunity and that I was scheduled for the second choice of treatment, namely, “go up and get it”. That is water under the bridge now, so to speak, because lithotripsy is definitely not an option at this point.

I was scheduled for 2:45 PM, but was called at home at noon to see if I could come immediately. Either they had a cancellation or other cases were moving faster than anticipated, but they were very anxious for me to get there ASAP. Surgeons do not like idle waiting times.

As they were putting in my IV, I glanced at the schedule board. There was a big time gap they were trying to fill so they could probably get home early, rather than sit around and wait for my later appointment. That’s okay, though. It was less time for me to worry and fret about it.

Three different nurses were rushing around trying to get me prepped for the pacing, impatient anesthesiologist, who was miffed that the IV wasn’t started yet. Had I known, I could have put it in myself. In retrospect, not having the IV in was a blessing. The anesthesiologist decided to do it himself. He asked if I wanted lidocaine to deaden the area of the needle, but I declined. Just go for it. Let’s get this dance started.

I am allergic to just one antibiotic. Guess which one was hanging on the IV pole ready to be administered to me? Yes…that one. A sharp nurse noticed it first and I anxiously confirmed that they came darn close to killing me. A very serious situation was avoided in time.  Years ago, I had a very serious allergic reaction to just one oral pill of this drug, resulting in a 911 call and a rush to the emergency room, and they were about to give me a huge dose by IV.

They were real careful about my name, however. They asked me my name at least TEN times; making me spell my first and last name and my date of birth. They confirmed over and over to make sure the name matched my chart and my wrist band. They did, however, miss the big red ALLERGY sticker on the front of my chart mentioning the antibiotic I was about to receive. More mistakes are made when people are in a hurry.

The surgeon arrived and confirmed the type of surgery I was getting and the location. She wrote the information directly on the skin of my left flank with a bright green marker. All patients look alike, lying on an operating table with an anesthesia mask over their face, so this practice is good. I can excuse the near-fatal medication error, but I would not be a happy camper if they did the wrong surgery or went in the wrong side. There are a lot of other horrible urological procedures she could have done worse than chasing a stone, had she made a mistake. We have all heard those stories. When my wife had surgery years ago, I made sure to do that writing before she went to the hospital. I put her name, the type of surgery directly on the spot they were cutting, and I also put the words, “Please, take good care of my wife!”

Music was playing in the bright operating room; and not good music either. The OR tech/DJ said that he would be willing to play any requests, but I didn’t really get a chance to ponder the best type music for kidney stones (or even check for any more mistakes) because I was out cold in seconds. Time is money and they didn’t want me witnessing any more embarrassing events.

I spent a lot of time in the operating room as a young clinician. The idea of having music playing in the background while we pulled out a gallbladder or inflamed appendix would have been considered inappropriate. Yes, we did a lot of talking (after the patient was asleep), but some vascular surgical cases lasted nearly eight hours. Talking distracted us from feeling hungry or suppressing the progressive need to pee.

I awoke in the recovery area about two hours later, pleased of course, that I did wake up.  I told the anesthesiologist that I did not want to wake up during surgery, but I expected to wake up at the end. That was his goal, too, but I thought I would mention it.

“I have some bad news”, said my wife. That’s a great thing to hear when you wake up from surgery. Before I even had a chance to see if any of my parts were not accidentally removed, she told me that the urologist was unable to get the stone out, after multiple attempts. The stone was just too big, and my ureter too stenotic (small and narrow) for the stone to ever pass. She placed a surgical stent – something to gradually (but not painlessly) enlarge the ureter so that she can (hopefully) get it next time. Next time?

One drug that is often given as a pre-op causes short-term amnesia as a side effect. Even if you experienced or witness a bad experience in the OR, like falling off of the table or running amok, you wouldn’t remember it. When my wife had a colonoscopy, the first thing that she wanted to do on the way home was get something to eat. She agreed to stop at Denny’s so I knew she was still out of it. After eating a huge breakfast, when we were back in the car, she said,

“Well? Are we going to stop and eat or what?”

When I informed her that she just wolfed down some pancakes, eggs, and tomato juice, she accused me of lying. Fortunately, I handed her the receipt and told her to read it; look at the date and time. To this day, she STILL does not remember eating at Denny’s, or anything about this event.

I remember most (not all, perhaps) of what went on yesterday. I did not eat at Denny’s on the way home. I didn’t feel like eating anything ever again.

This afternoon, 24-hours after surgery, I get a call from the recovery room to see how I was feeling, so I told them. Her Eastern European accent was so heavy; I had to have her repeat what she was saying over and over again, slower each time. I guess she was expecting me to say “fine”, but I had lots of questions. She could not answer any of them, other than, “Pain after surgery normal” and “Still have catheter?” I told her no. She said, “Are you sure?” I responded that I think I would have noticed a catheter.

Another attempt will be made to get that stone out in ten days. So, there will be at least ten more days of pain and suffering; the type of pain that is not helped by any pain medication.  A person could take the strongest pain medication available and then hit their thumb with a big hammer. It is still going to hurt and there is nothing that would prevent that.

I informed my office that I will not be back to work for quite a while longer. This is the longest period that I have not worked in my entire career — one month and counting. For the first time in my life, I am entitled to some meager, state disability payments if I can figure out how to complete the volume of paper work required. My company’s own short-term disability policy does not kick in until after thirty days, so filling for any benefits would be futile.

What could be worse? A few minutes ago, I was served a subpoena to appear in court as a witness for a trial starting in a just a few days. This was the first I heard about it. About 15 or more years ago, I worked for the Child Protection Center performing evidentiary examinations on children who were sexually abused — the most heart-tugging and stressful job in my career. It appears that one of the convicted perpetrators, likely still in prison, is trying to get a new trial or trying to be released on some technical flaw in the case. Starting early this morning, I have left dozens of messages with the District Attorney’s office. I am definitely not capable of being drilled for hours on the stand about evidence collection or my recollections on a case 15 years ago. I did over 200 of these exams during my employment, and I have no memory of any of them…anymore. These are the cases you pray to forget.

It is not bad enough to have groin and flank pain from the mother of all kidney stones; now I have this to contend with new “pain”. At least the new pain is in the same general area.

Posted by: Rod Moser, PA, PhD at 11:26 am

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