Friday, April 13, 2012

when even morphine lets you down: lacerated kidney and ER visit #2

Manuel Orazi’s illustration for the 1906 novel by Du Saussay
So as I said I was discharged early Saturday night, disheartened about the whole situation, but thinking I could survive 2 weeks off from working out; in fact maybe it would give me a chance to get caught up on my gardening and writing. I took the naproxen before bed but then woke up at 3 am in what I thought at the time was the worst pain ever. I was wrong. The scariest part was the amount of blood I was passing, I mean the toilet looked like someone had been murdered, and there were pieces of something in the bottom of the bowl. Blood clots? Pieces of my kidney? Yeah a little unsettling, even for me. I stumbled down the stairs in the dark, opened the glass grain cabinet that had once housed my sister's stereo in college (remember those days, when you needed a cabinet for all of your audio equipment?) and my trembling hand knocked my stash of orange plastic prescription drug containers off the shelf as I reached for the the morphine that had been prescribed after my shoulder surgery in 2009. I stared at the little blue pill for a second and wondered how badly this thing would tear up my intestines but the pain was absolutely unbearable, so down the hatch it went. Within 15 minutes the pain subsided and I was able to sleep until 8 am. When I got up to empty my bladder it was as I feared: again the water was a deep crimson and there was what looked like delicate little petals on the bottom of my elegant Kohler toilet. At that point the morphine was keeping the pain somewhat under control so I got up, fed the dogs and ate a bit of cereal.

I called up Dr. Mark and he suggested I head back to the ER, but I had no desire to spend a beautiful Sunday at HUP exposing myself to a MRSA infection just to hear that there was nothing they could do for me. On the other hand the Massacre in the Toilet made me wonder if I needed more medical care. I was feeling increasingly crappy. Damn, it was April 1st and I had so many seeds that needed to be planted this weekend; and I had been planning on going to this, but considering I was not supposed to be doing much jostling of my kidney and the Convention Center was the size of a couple of football fields I decided not to attend. Which meant that I would miss a seminar on beekeeping I needed to hear to motivate me to get off my a@@ and get the heck out of Kill-adelphia.

    Salvador Dali, The Bleeding Roses, 1930

So I called the number for the ER on my discharge sheet, and the nurse who spoke to me suggested I return immediately. But in my experience most nurses are not particularly nuanced in the differences between healthy but accident-prone people and the heart-diseased, obese, diabetic folks they see en masse, so I called up the service for the Trauma Surgeon, Patrick Kim, MD, who had seen me on Saturday and who I had immediately liked.  I knew he would give me the straight scoop.

If you are unlucky enough to find yourself a guest in an emergency room you are invariably graced with a string of doctors, residents, RNs and other hospital staff who interview you, treat you, and interpret your test results.  At a teaching hospital like HUP, many are residents, and most are pretty forgettable.

Although Patrick Kim MD is the Trauma Program Director, meaning the Surgeon overseeing the program and thus had the requisite ego, I could tell immediately that he possessed not only the strong intellect required to procure a position at one of the top hospitals in the country, but also a keen sense of intuition which was lacking in many an A-list doctors. I surmised that Dr. Kim had been briefed by the residents who had interviewed me prior to the Head Honcho arriving that I was a knucklehead who was quite skilled at bashing my body into stationary objects; be they trees, random rock formations, wanton wheelbarrows, or in this case, the ground, and I had been no stranger to emergency rooms in my lifetime. He knew he needed to send a message loud and clear that I needed to let my kidney heal properly.

Saturday afternoon he strode into ER Bay 10, flanked by two residents and one other doctor from the trauma team. I had been reading the New York Times on my Ipad when suddenly there were a bunch of white coats looking down at me.

"Ms. Walheim," Dr. Kim said.
"Hello" I managed weakly. His authoritative voice jerked me back to reality.
"You really messed up your kidney," he stated, speaking without a tinge of levity.
"That's what they say," I mused, my smile an olive branch. He was actually pretty cute, I thought.

We had a 15 minute interview, and he went over the tests and prognosis, and as we talked back and forth and he could see I was intelligent, an athlete committed to a healthy lifestyle, and possessed a strong understanding of medical language and concepts he loosened up, smiled and talked a bit about himself and his wife. The brilliant doctors are quite comfortable with the educated patient.

 And that's when he told me I could not do any exercise for two weeks.
"I have to ask this, " I said, "What do you consider exercise?  Because if you don't say otherwise, I will be back in the pool in a few days, " I admitted.
"No exercise means nothing," he said firmly, "Bedrest for 2 weeks. This is a serious injury Ms.Walheim.   If it gets any worse you could get an infection and you could need surgery, so it's up to you."
"No, thank you for clarifying," I hastily said, "I just need to understand the nature of the beast."
"Well you can get caught up on your sleep then, " he said, "because I bet you don't get enough sleep."
I have no idea if that was just a good guess, but I smiled and agreed.
So that was Saturday.

Back to Sunday morning, imagine my surprise when I was able to get Dr. Kim himself to call me back as I sat on the couch in pain and misery, with a profusely bleeding kidney.  He said that if I was able to control my pain at home, I did not need to return to the hospital.  This was great news.

In retrospect, I really don't know if I did too much on Sunday, or if the trajectory of this injury had already been predetermined by the biological domino effect of me slamming my left side into the ground a few days before.  I did get through the day and took another morphine before bed, but somehow, by 4:30 am, the 12-hour pill had stopped working.  The pain was so intense I could barely get out of bed.  I had never quite felt anything like this, not even when the tire of that truck was rolling up my leg and I felt my bones and flesh being snapped and crushed with the pressure.  Surely there was something else really wrong with my kidney.

CT Scan number two
I called 9-1-1.  My voice was hardly intelligible when the Operator answered the call.  I was sobbing in pain.  I told her that I had a lacerated kidney and I needed to go back to HUP, so she connected me with the ambulance service.  I stumbled around collecting a few things, trying not to upset Madison and Chloe, and only about 14 minutes later there were two EMTs standing on my front porch.  I made it down the stairs and through the wall of barking dogs and opened the door.  I told them about my kidney, stepped out on the porch, locked the door and gingerly climbed into the back of the ambulance.

The EMT at the wheel said to the other, "Which hospital?"
"Temple," he replied.
"We have to go to HUP" I said, grimacing in pain, "they have all my medical records and they already did the CT Scan and x-ray, I don't want to start over at Temple." Plus I really did not want to go to North Philly.
"We have no choice," the EMT said, "we get in trouble if we pass a hospital."

So I apologized and thanked them, but told them to go.  I then re-entered my house and called Chris, which was my last remaining option before I would attempt to drive my own sorry self to HUP.  He answered the phone to my surprise.

"I need a ride back to the ER now," I cried, "I feel like I'm going to die...and there is even more blood."
"I will be there in twenty minutes."

So that is how I ended up back in the ER.  When I finally got through registration and back to Bay 11 this time, a wonderful nurse named Kim took one look at my face, looked through my records, inserted my IV and pumped Dilaudid into my arm.  A burning....then the horrible pain evaporated within minutes.  Incredible.  Of course I was also immediately nauseated and actually threw up a few times but they added in Zofran for the nausea and I was passed out on the bed a few minutes later, now a character in a opiate-induced Salvadore Daliesque dreamscape.

Salvador Dali's  Dream Caused by the Flight of a Bumblebee
around a Pomegranate a Second Before Awakening
, 1944 
  
 Kim was pure magic, she always seemed to be there when I needed more Dilaudid or something to vomit into.  At some point they wheeled me down for another CT scan to make sure nothing horrible had happened, which it hadn't, and of course I threw up again. I was discharged at noon with a script for Percoset and Zofran, and told that the pain would be rough but I had to keep on top of it with medication. Chris drove me to the pharmacy and then I went home and fell into another delaudid induced dreamstate.
He walked the dogs while I slept, then I got up and actually entered the payroll so everyone at Liberty could get paid that week.
I managed to feed the dogs later, then I took my percoset pills and went to bed, thinking the ordeal might be over.  I was wrong.  

Saturday, April 7, 2012

why mountain biking can be dangerous: ER visit #1





So Thursday as I usually do I drove the dogs and the Yeti to Belmont so we could ride for 90 minutes and thus I could consolidate my workout and the dogs'.  It is a tribute to the rigors of raw-feeding that my 10 year old twins can hang with me while I'm riding. Especially Madison, who is two weeks post-op. When I'm riding with the two girls in the woods, Chloe out front scouting out the trail about 40 feet ahead; Madison's whiskers practically brushing my back wheel; I  feel sometimes like I am Diana and we are hunting somewhere on the plains of Europe a thousand years ago.  Then I see a dirty condom wrapper or some other remnant of the urban park that is Belmont Plateau and I'm right back in Philadelphia, Pennsylvania in the year 2012.  It can still be epic though.

So imagine my surprise when I steer around a tree and over a log I have gone over a hundred times before and I somehow manage not to pull up my front wheel at the split second necessary to clear the obstacle.  My wheel stops suddenly, and as these mistakes often end I am rudely catapulted from the bike; land on my head and left side and feel a crushing pain in my spine. Awful. This was no ordinary fall. I lay there in the middle of the trail on my stomach for probably a full minute. Madison came over and sniffed my mouth, whining with concern. I think she tried to give me snout-to-mouth resuscitation. A minute later Chloe bounded back and nudged me. I was moaning and trying to get up.

I finally picked myself up, and realized that I would not be able to ride back to the car, so I dragged my bike up a hill through the underbrush and managed to get back on the gravel access road, at which I did hop on the cursed piece of bubblegum pink metal and ride the few hundred yards back to the car. The ride had lasted 31 minutes...Ss-weet. Madison whined as we neared the car because she was not ready to end the fun but I was trying to figure out how I was going to drive home. The pain was excruciating now.

We did get home and I ushered the dogs into the house and then leaned against the car, wondering how I was going to lift the Yeti up the 10 steps outside my house to get it in the door. My neighbor was there, smoking, leaning against his porch two houses down but I just could not ask a smoker to help me, call me stupid.  So I picked up the bike, brought it up onto the porch, and then ran into the house and threw up into the kitchen sink.

I moped around for awhile, but I could hardly move, and I thought maybe I should take a pain pill, which I only do in extreme circumstances.  I texted Steve Collina, MD and he called me back after his ride and urged me to take the prescription naproxen I had on hand for a few days. So I waited and then took it before bed, which enabled me to sleep through the night, and I was able to actually walk around and even take the dogs to the Wiss on Friday. I worked from home and even stopped at Whole Foods. But I started noticing I was peeing red, and it was not until Saturday am when the hematuria got much worse that I realized that the red color of my urine was not from my usual beet consumption but from a bleeding left kidney. My pain was localized right over the kidney on the left.

So of course I googled "blood in urine female" and managed to convince myself that this was actually no cause for concern, that I had bruised my kidney and it would get better on its own. But since the blood was getting more concentrated, I decided to email Brian Shiple, DO from the Center for Sports Medicine, since he knows my history all too well as he has been treating me since 1996, is currently curing my endocrine disorder, and he was not afraid of lawsuits like some of my other doctor friends so he would not make a mountain out of a molehill.

Subject: hematuria from mountain bike fall--your advice?
From: Andrea
To: Brian Shiple, DO
Date: Mar 31 (7 days ago)


Dr. Shiple, I am so sorry to bother you on a Saturday but before I call my PCP answering service I wanted to run this by you because you understand my medical history etc.  I took a bad spill on the bike Thursday, felt my spine compress and there was severe pain on left side lower back (where I always get back pain after gardening, during my period, etc--where you did most of my prolo back in the day).  I actually had to walk out of the woods, I felt terrible.  Pain was intense but my immune system always has a very exaggerated inflammatory response.  Although I hate pain meds because they interfere with healing, Collina convinced me to take Naproxen 500mg 2x per day since I had them here anyway, which was a good idea because without them I'm not able to do much.  They really keep the edge off so I'm able to walk the dogs etc.

Saw Dr. Mathews last night and he put 2 ribs back into place.  He said my muscle was spasming in lower back.  My lower back on that side is swollen.  I think the thing will heal, I don't think it's slipped disk because I only got numbness in the left leg for a couple hours when I went to Whole Foods.  But the blood in my urine has increased since Thursday, this am (first pee-concentrated) was very red and still now it's pretty red.  Do I need to worry about that?

Do you think I should make an appt for some kind of MRI or CT or just wait and see what happens?  I guess I could call the doc on charge at my PCP but they are clueless about athletes.  I have never had blood in my urine before though, with all of the spills I have had.  It's not a UTI, I don't get them. 
I know, I'm an idiot but I do want my kidney to remain functional for the next half a century. A

Subject: hematuria from mountain bike fall--your advice?
From: Brian Shiple, DO
To: Andrea
Date: Mar 31 (7 days ago)


Yea having working kidneys is a good thing Andrea. You need an ER eval with xray and most likely a CT scan for persistent hematuria d/t trauma. You can follow up with Collina or if we can fit you in with me, but either way is fine.
prepared with full medical history/non-phila drinking H20/Ipad/Droid

Brian J. Shiple, D.O.
Board Certified Sports Medicine
The Center for Sports Medicine,
905 West Sproul Rd, Suite 106
Springfield, PA 19064
Office-484-472-8812
Fax-484-472-8878
www.drshiple.com



Subject: hematuria from mountain bike fall--your advice?
From: Andrea
To: Brian Shiple, DO
Date: Mar 31 (7 days ago)


what is ER?


Subject: hematuria from mountain bike fall--your advice?

From: Brian Shiple, DO
To: Andrea
Date: Mar 31 (7 days ago)


Emergency room. Go to the ER today so you can get your helical CT of your kidneys.

Brian J. Shiple, D.O.
Board Certified Sports Medicine
The Center for Sports Medicine,
905 West Sproul Rd, Suite 106
Springfield, PA 19064
Office-484-472-8812
Fax-484-472-8878
www.drshiple.com





Subject: hematuria from mountain bike fall--your advice?
From: Andrea
To: Brian Shiple, DO
Date: Mar 31 (2 days ago)


Really?  Crap. Ok. Thank you and have a good weekend.




So I got asked Chris to drive me to the Hospital of the University of Pennsylvania because they have a better trauma team there than at Penn Presbyterian Hospital.  I was prepared to languish forever in the waiting room, but after they checked me in they asked me to pee in a cup and as you can see it was quite crimson by now, so they brought me right in to Bed #10.  After the requisite questions and documentation they wheeled me down to have a CT scan.


the CT Scan at HUP

They stuck an IV in my arm for the dye because the CATSCAN ordered needed contrast, and I also received a chest x-ray.  When all was said and done it was determined that I had a laceration of my left kidney, the side I had fallen on, and the laceration was probably accomplished by my own rib, which is best illustrated by the following pictures:




Here is a view from my Real Bodyworks anatomy app on my Ipad.  You can see the left kidney in relation to the last floating rib.  The lower ribs tend to break less often than the ones anchored to the breastbone because of their flexibility, but in my case the rib did not fracture, so we theorized that the kidney was jostled by the fall and actually bounced off the rib.  This is probably better illustrated by the second picture which is rotated towards the left side of the body.  At any rate, without an actual piece of rib left sticking out of the kidney this is all a theory but apparently it is not an uncommon injury.

So since my pain was controlled with the naproxen, they suggested I switch to Tylenol because naproxen has blood thinning properties, and sent me home Saturday night.  As I tucked myself gingerly into bed I found that I did not have any Tylenol, and besides you have to take Tylenol every 4 hours and naproxen would get me through the night.  So I popped one in my mouth and went to bed, thinking about how miserable I was going to be not exercising for 2 weeks.