Acetabular Labral Tears
by Cara L Lewis and Shirley A Sahrmann
PHYS THERVol. 86, No. 1, January 2006, pp. 110-121
Anterior hip or groin pain is a common complaint for which people are referred for physical therapy, with the hip region being involved in approximately 5% to 9% of injuries in high school athletes.1 Although anterior hip pain is known to result from a number of musculoskeletal and systemic pathologies, a tear of the acetabular labrum is a recent addition to the list that is of particular interest to physical therapists. This mechanically induced pathology is thought to result from excessive forces at the hip joint2,3 and has been proposed as part of a continuum of hip joint disease that may result in articular cartilage degeneration.2 Although the number of recent articles in the orthopedic literature identifying acetabular labral tears as a source of hip pain is increasing, labral tears often evade detection, resulting in a long duration of symptoms, greater than 2 years on average, before diagnosis.4–8 Studies have shown that 22% of athletes with groin pain9 and 55% of patients with mechanical hip pain of unknown etiology2 were found to have a labral tear upon further evaluation. In order to provide the most appropriate intervention for patients with anterior hip or groin pain, physical therapists should be knowledgeable about all of the possible sources and causes of this pain, including a tear of the acetabular labrum and the possible factors contributing to these tears. Therefore, the purpose of this article is to review the anatomy and function of the acetabular labrum and present current concepts on the etiology, clinical characteristics, diagnosis, and treatment of labral tears.
Acetabular Labral Tears of the Hip: Examination and Diagnostic Challenges
RobRoy L. Martin, Keelan R. Enseki, Peter Draovitch, Talia Trapuzzano, Marc J. Philippon
J Orthop Sports Phys Ther. 2006:36(7):503-515. doi:10.2519/jospt.2006.2135
The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging.
Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.
Video of Hip Exam from this Article
The Hip Joint: Arthroscopic Procedures and Postoperative Rehabilitation
Keelan R. Enseki, Peter Draovitch, Bryan T. Kelly, RobRoy L. Martin, Marc J. Philippon, Mara L. Schenker
J Orthop Sports Phys Ther. 2006;36(7):516-525. doi:10.2519/jospt.2006.2138
Recent technological improvements have resulted in a greater number of surgical options available for individuals with hip joint pathology. These options are particularly pertinent to the relatively younger and more active population.
The diagnosis and treatment of acetabular labral tears have become topics of particular interest. Improvements in diagnostic capability and surgical technology have resulted in an increased number of arthroscopic procedures being performed to address acetabular labral tears and associated pathology. Associated conditions include capsular laxity, femoral-acetabular impingement, and chondral lesions. Arthroscopic techniques include labral tear resection, labral repair, capsular modification, osteoplasty, and microfracture procedures.
Postoperative rehabilitation following arthroscopic procedures of the hip joint carries particular concerns regarding range of motion, weight-bearing precautions, and initiation of strength activities. Postoperative rehabilitation protocols that have been typically used for surgeries such as total hip arthroplasty are often not sufficient for the population of patients undergoing arthroscopic procedures of the hip joint. Postoperative rehabilitation should be based upon the principles of tissue healing as well as individual patient characteristics. As arthroscopic procedures to address acetabular labral tears and associated pathology evolve, physical therapists have the opportunity to play a significant role through the development of corresponding rehabilitation protocols.
Video of Hip Arthorscopy from this article
Acetabular Labral Tears
J Bone Joint Surg Am. 2009;91:701-710. doi:10.2106/JBJS.H.00802
Paul E. Beaulé, Michelle O'Neill and Kawan Rakhra
Acetabular labral tears rarely occur in the absence of a structural osseous abnormality.
Labral tears are frequently associated with lesions of acetabular cartilage such as delamination.
Hip arthroscopy is the preferred operative approach in the treatment of labral injuries in the absence of substantial structural osseous abnormalities.
see a later posting for more on this article
Showing posts with label hipscope. Show all posts
Showing posts with label hipscope. Show all posts
Thursday, May 1, 2008
Saturday, March 29, 2008
5 Month and 9 Month Hip Updates
I haven't mentioned my hips in a while as other things have taken precedence lately. But here we go:
I am back to normal, or as normal as I will get with scoped hips. I will not use the treadmill, I think it is too hard on them and I really want to keep "these" hips for as long as possible.
I am getting more aches and pains now than I did before the knee thing (BTKT) began, so I totally attribute it to compensation. Previously, I had almost no achiness. Now I occasionally get achiness, right more than left (right was scoped twice), my adductors still get spasmy occasionally, more now than BTKT. I also now have a alot of clunking and clicking in both, I think left more than right. It is painless but loud. I have gotten into he habit of "cracking" my back, so I use various techniques, adopted from what I would use in the clinic. I always say that whatever needs to crack will crack with a manipulation, so at time, I will be focusing on my low back/ SI joint and will get a nice crack in a hip. I still hold onto the theory that it is scar tissue, and I don't worry one drop about it because it is painless, there is no FAI in either hip anymore so I won't tear my labrum again, plus, a good chunk of labrum was debrided so even less likely to tear (bc it is gone), and it is important to stay positive.
My IT bands get tight and tender sometimes, but I think they always were, even before the hip shit started. My "invisible bruise" on the right is still there, believe it or not. It does not interfere with my life anymore and the box of lidocaine patches sits on my desk, untouched. The area does consistently get smaller but the pain level is about the same, just in a smaller area.
I can push my stroller with no hip pain, I spin with no hip pain, I work with no hip pain, what more can I ask for :-)
A big part of healing, and healing well, is staying positive, focusing your energies and returning to life and moving past this messy chapter, and always remembering, things could always be worse!
I am back to normal, or as normal as I will get with scoped hips. I will not use the treadmill, I think it is too hard on them and I really want to keep "these" hips for as long as possible.
I am getting more aches and pains now than I did before the knee thing (BTKT) began, so I totally attribute it to compensation. Previously, I had almost no achiness. Now I occasionally get achiness, right more than left (right was scoped twice), my adductors still get spasmy occasionally, more now than BTKT. I also now have a alot of clunking and clicking in both, I think left more than right. It is painless but loud. I have gotten into he habit of "cracking" my back, so I use various techniques, adopted from what I would use in the clinic. I always say that whatever needs to crack will crack with a manipulation, so at time, I will be focusing on my low back/ SI joint and will get a nice crack in a hip. I still hold onto the theory that it is scar tissue, and I don't worry one drop about it because it is painless, there is no FAI in either hip anymore so I won't tear my labrum again, plus, a good chunk of labrum was debrided so even less likely to tear (bc it is gone), and it is important to stay positive.
My IT bands get tight and tender sometimes, but I think they always were, even before the hip shit started. My "invisible bruise" on the right is still there, believe it or not. It does not interfere with my life anymore and the box of lidocaine patches sits on my desk, untouched. The area does consistently get smaller but the pain level is about the same, just in a smaller area.
I can push my stroller with no hip pain, I spin with no hip pain, I work with no hip pain, what more can I ask for :-)
A big part of healing, and healing well, is staying positive, focusing your energies and returning to life and moving past this messy chapter, and always remembering, things could always be worse!
Thursday, February 14, 2008
The Start of Something Great
Yesterday was my 3 month follow-up with Dr. Kelly. For the first time ever, I left happy, satisfied, elated, thrilled...... We actually didn't discuss another surgery. I have never left his office without having a sinking feeling that this disaster was not ending. I think I had a smile on my face for the rest of the day. I know in the past I have said I was really happy and this is over, but this office visit gave me closure! We barely even discussed my hip, I told him it was great, and I am REALLY happy! Really really really happy!
The visit was even more fun bc I had entertainment! I brought L along, since she is OBSESSED with bones, as well as Amy, who had an earlier appointment and ended up hanging out with us. L really wanted to see x-rays, and she has been talking about seeing them and meeting Dr. Kelly for a while. She is such a funny kid. She even got to leave school early for it. But when the 3 of us got into a room, she became timid, and when he came in the room, she buried her head in my lap and wouldn't look up!
The visit was even more fun bc I had entertainment! I brought L along, since she is OBSESSED with bones, as well as Amy, who had an earlier appointment and ended up hanging out with us. L really wanted to see x-rays, and she has been talking about seeing them and meeting Dr. Kelly for a while. She is such a funny kid. She even got to leave school early for it. But when the 3 of us got into a room, she became timid, and when he came in the room, she buried her head in my lap and wouldn't look up!
He was excited to show her x-rays, he was even going to get her some MRI's if she wanted to!
He started by showing us my scope pics, especially my "intact" (and absolutely beautiful and perfect) psoas. Lots and lots of shots of my psoas, (for the lawyers, of course, he joked). He told me I was very scary when I "threatened" him during out psoas conversations and the pre-cursor to the psoas conversation. He let L have a sheet of scope pics! She was still buried in my leg but when we got home she was so excited to show J and Jk.
He started by showing us my scope pics, especially my "intact" (and absolutely beautiful and perfect) psoas. Lots and lots of shots of my psoas, (for the lawyers, of course, he joked). He told me I was very scary when I "threatened" him during out psoas conversations and the pre-cursor to the psoas conversation. He let L have a sheet of scope pics! She was still buried in my leg but when we got home she was so excited to show J and Jk.
He checked my hips, and found the right to have more ROM (right was scoped 2x), he said it was because he had taken down a lot more bone in the right. I think this explains why I was having a lot of muscular issues there. I now have the ability to move more, but my muscles needed to be retrained in this new range. Kind of like what happened during my continuing ed course.
Of course the conversation turned to football (I will let Amy tell you about that part of the visit as well as the rest of the day, plus the best pic of the day)
But...he kept saying "she was right, she was right", (meaning, there was bony impingement in my hip the whole time) see, I knew I was not making this up August-November. And to think of all the times I nearly lost it during those months!
So things went super, I asked if he wanted to see me again....he laughed! I need an x-ray at 1 year out, I can handle that!!
As I was finishing up with the receptionist, he came back out and told me to come back and bring my chart. He had the Chief Resident there, he took out my scope pics and said "this is why you need to listen to your patients"!!
Sunday, February 3, 2008
Turning the Bend
I think tomorrow is 12 weeks post-op, wow, how time flies when you are having fun! I can't believe I have had the privilege of experiencing 3 hip arthroscopies, how did I ever get so lucky!
Thankfully, everything went super this last time! I attended PT a whopping 3 times this week, I guess that takes care of the dropout status, for now anyway. J is traveling this week so I won't be making it in early to have P work on me, so this week I revert to drop-out status once again. The only thing is, I may really need P tomorrow. My SI joint is giving me grief this week. It was giving him grief as well Friday, I asked him to manipulate it, which is a high velocity, low amplitude thrust that if done correctly, will generally result in a "pop". I am generally a great "popper" but it would not go for him. I was so sore all day Friday and Saturday as well. Today it feels better but I am keeping my fingers crossed that it remains like this. SI pain stinks, I develop a deep achiness right along my PSIS. It is definitely not my first bout of SI pain though, at one pint in time, I had taught J how to fix it for me, the only trouble this time is that I am not sure what type of dysfunction I am having so cannot instruct him in correcting it. I find that in the past, I am always developing 'issues' on the weekend, when I have no access to 'help'! SI joint issues are a small price to pay for hip relief, and I will take this any time over groin pain, losing my mind, and another surgery!
Thankfully, everything went super this last time! I attended PT a whopping 3 times this week, I guess that takes care of the dropout status, for now anyway. J is traveling this week so I won't be making it in early to have P work on me, so this week I revert to drop-out status once again. The only thing is, I may really need P tomorrow. My SI joint is giving me grief this week. It was giving him grief as well Friday, I asked him to manipulate it, which is a high velocity, low amplitude thrust that if done correctly, will generally result in a "pop". I am generally a great "popper" but it would not go for him. I was so sore all day Friday and Saturday as well. Today it feels better but I am keeping my fingers crossed that it remains like this. SI pain stinks, I develop a deep achiness right along my PSIS. It is definitely not my first bout of SI pain though, at one pint in time, I had taught J how to fix it for me, the only trouble this time is that I am not sure what type of dysfunction I am having so cannot instruct him in correcting it. I find that in the past, I am always developing 'issues' on the weekend, when I have no access to 'help'! SI joint issues are a small price to pay for hip relief, and I will take this any time over groin pain, losing my mind, and another surgery!
Monday, December 10, 2007
First Day Back
I WENT TO WORK TODAY!!!!!!!!!!!!!!!!
So...you want to know how it went? I actually had pain. Surprise? Not really, my job is pretty physical and was a killer pre-op. At first I was nervous bc I thought I had joint pain but it turned out to be adductor pain, which is, well, a pain, but manageable!
I was planning on taking Naprosyn when I got home (I know, big Crohn's no no) but ended up not needing it. So once again, I am flying high on life (yes, nothing else).
I skipped PT today since there was no way I was going to survive a day at work after therapy, so I will be going Wednesday only this week! We need to work on my abductor strength. I was demonstrating a step up/ down for a patient and noticed that my leg totally collapsed inward during the step down. I need to do that to head off the knee pain that will surely follow if not taken care of!
I will have P strength test me Wed. and give an update.
For those of you still having trouble, I do not mean to rub it in your faces. I have been there and want you to know that there is a light at the end of the tunnel! And when you get there, I will be there, cheering you on!
So...you want to know how it went? I actually had pain. Surprise? Not really, my job is pretty physical and was a killer pre-op. At first I was nervous bc I thought I had joint pain but it turned out to be adductor pain, which is, well, a pain, but manageable!
I was planning on taking Naprosyn when I got home (I know, big Crohn's no no) but ended up not needing it. So once again, I am flying high on life (yes, nothing else).
I skipped PT today since there was no way I was going to survive a day at work after therapy, so I will be going Wednesday only this week! We need to work on my abductor strength. I was demonstrating a step up/ down for a patient and noticed that my leg totally collapsed inward during the step down. I need to do that to head off the knee pain that will surely follow if not taken care of!
I will have P strength test me Wed. and give an update.
For those of you still having trouble, I do not mean to rub it in your faces. I have been there and want you to know that there is a light at the end of the tunnel! And when you get there, I will be there, cheering you on!
Wednesday, November 28, 2007
My 1 Year Anniversary
Today marks the 1 year anniversary of when my hip saga began. For anyone just beginning their journey, I can assure you that in the hands of the right surgeon, there is a light at the end of the tunnel. I am going to do a flashback to November 28, 2006.
Shit, my hip hurts. It hurts when I drive, and especially when I push the kids in the double stroller. It is a really annoying pain. It feels like something is in my joint. My friend/ PT is coming into work around 3, I will ask her to work on it and hopefully get some relief. She showed up and I told her I was dying of pain, she did a painful release on my iliacus/psoas, I felt better immediately, but in the car on my way home, things got bad again.
I went into work the next day, again, in agony. First I had one therapist stretch my hip flexors and ITB, thinking this may help. Then I had another one check it out. She said there is definitely some kind of impingement. Then I asked P for help. He was really busy so I waited until he was done seeing patients. What makes the day so memorable is that it was Jk's 1st birthday, and I was having a small dinner party, and lacking a few key ingredients. I used P's full schedule to run to the supermarket near my office but didn't find what I was looking for (which I now don't even remember what it was). P did all kinds of releases, ART, mulligan mobs...It felt good...until I was in my car again. Shit. What is this????
I got home, L had ballet and there was no food for my party! I ended up ordering pizza, Jk didn't know the difference! After we had cleaned up and the kids were in bed, I hit the computer. I had a feeling I had a labral tear, and the word impingement reverberated through my head. I think I first looked for a surgeon, before I did anything else, that is me, always thinking ahead! I was trying to remember when I had seen a hipscope, and who did them, and no one was popping into my head. At the time, there was a hipscope patient in my office and she was a wealth of information, but I wasn't willing to see her surgeon (he was in NJ), I knew it had to be someone at HSS. So I looked and searched, and researched labral tears, FAI.....Not just that night, but every night after that for weeks. After a week or 2, I decided this wasn't getting and made an appointment with Dr.Kelly. I was between him and another surgeon. I had emailed a professor of mine about this and he had recommended against the other surgeon for personal reasons. So Dr.Kelly it was. If things didn't go well, then I would pursue other options, it was just a consult, right. Hopefully he would order an MRI and get to the bottom of this. The rest is history....but in a nutshell...
3/5/07 R hip arthroscopy, Pincer impingement, labral tear debridement, synovectomy
7/2/07 L hip arthroscopy, Cam and Pincer impingement, labral tear debridement, synovectomy
11/12/07 R hip revision arthroscopy, Cam impingement, removal of scar tissue, synovectomy, upon examination, found to have beautiful psoas
11/28/07 Riding high on life (bc everything else makes me sick) and enjoying a painfree lifestyle, looking forward to ditching my single crutch very very soon! :-)
Shit, my hip hurts. It hurts when I drive, and especially when I push the kids in the double stroller. It is a really annoying pain. It feels like something is in my joint. My friend/ PT is coming into work around 3, I will ask her to work on it and hopefully get some relief. She showed up and I told her I was dying of pain, she did a painful release on my iliacus/psoas, I felt better immediately, but in the car on my way home, things got bad again.
I went into work the next day, again, in agony. First I had one therapist stretch my hip flexors and ITB, thinking this may help. Then I had another one check it out. She said there is definitely some kind of impingement. Then I asked P for help. He was really busy so I waited until he was done seeing patients. What makes the day so memorable is that it was Jk's 1st birthday, and I was having a small dinner party, and lacking a few key ingredients. I used P's full schedule to run to the supermarket near my office but didn't find what I was looking for (which I now don't even remember what it was). P did all kinds of releases, ART, mulligan mobs...It felt good...until I was in my car again. Shit. What is this????
I got home, L had ballet and there was no food for my party! I ended up ordering pizza, Jk didn't know the difference! After we had cleaned up and the kids were in bed, I hit the computer. I had a feeling I had a labral tear, and the word impingement reverberated through my head. I think I first looked for a surgeon, before I did anything else, that is me, always thinking ahead! I was trying to remember when I had seen a hipscope, and who did them, and no one was popping into my head. At the time, there was a hipscope patient in my office and she was a wealth of information, but I wasn't willing to see her surgeon (he was in NJ), I knew it had to be someone at HSS. So I looked and searched, and researched labral tears, FAI.....Not just that night, but every night after that for weeks. After a week or 2, I decided this wasn't getting and made an appointment with Dr.Kelly. I was between him and another surgeon. I had emailed a professor of mine about this and he had recommended against the other surgeon for personal reasons. So Dr.Kelly it was. If things didn't go well, then I would pursue other options, it was just a consult, right. Hopefully he would order an MRI and get to the bottom of this. The rest is history....but in a nutshell...
3/5/07 R hip arthroscopy, Pincer impingement, labral tear debridement, synovectomy
7/2/07 L hip arthroscopy, Cam and Pincer impingement, labral tear debridement, synovectomy
11/12/07 R hip revision arthroscopy, Cam impingement, removal of scar tissue, synovectomy, upon examination, found to have beautiful psoas
11/28/07 Riding high on life (bc everything else makes me sick) and enjoying a painfree lifestyle, looking forward to ditching my single crutch very very soon! :-)
Sunday, November 25, 2007
Thanksgiving Fun Cont.
Luckily we are home and have no stairs! I have minimal pain, could probably benefit from Tylenol but I have a huge aversion to anything that closely resembles a pill, or may possibly be medicinal. I didn't leave the house all day yesterday but took care of the kids crutchless. This involved breakfast, playing, lunch, naptime, snack. Luckily J did all the packing and loading of the car. We tried to minimize the stairs and stay on one level as much as possible. Stairs in and of themselves don't seem to be a problem, it was actually easier to them crutchless using a step through pattern as opposed to a step to pattern. But the hip really feels good. I have a little move I call my 'making sure I still have pain...or am I losing it', it was especially helpful post-injection 1 and 2 when the radiologist did not do a pre and post test. I stand on the affected leg and internally rotate the hip by turning my body away (out).If there is impingement, it pinches. It no longer pinches on the right, YAY!!!!! I am cured! I will have a 'brace throwing away event' soon. Interestingly, I held onto it after my first scope, something in the back of my head said to keep it. I still have the left brace too but I will toss it as well. Anyway, I wore it one day after this scope.
This morning we took the kids to a holiday cookie baking and magic show (the magician didn't show up though), it is at L's school so we walked. I walked with 2 crutches but left 1 in the stroller when we got there. Later we went out for pizza and I took one crutch. I get tired after a while, that's why in the house I was ok, I wasn't going very far in one stretch.
But it is so nice to be home, like any good Jewish family, there are always in-law issues, sibling issues and plenty of food! I have never eaten so much dessert before, hopefully my body needed all those extra calories to heal!
I return to PT tomorrow, I am not sure if I will go more than one time this week. Dr. Kelly wants me to take it slow, and it is Jk's birthday on Thursday, we are going to see Playhouse Disney Live! I will let P check my ROM and see what he thinks. Extension is going to be my biggest issue this time around I think, and I am developing some trochnateric bursitis, I think. I am still awfully bruised on the trochanter and medial to the incisions. It makes me wonder if they ever found the cushioning device that was 'missing' pre-op. L says my femur is very purple. Yes, she says femur. She is very into anatomy, and at 3, it i impressive, She knows the following bones: Scapula, clavicle, humerus, radius,ulna, phalanges, femur, patella, tibia, fibula, calcaneus. She loves medical dramas as well. We watch House, Grey's Anatomy, Private Practice and Scrubs.
I have some cute pics, we have a new camera so I will try to get J to upload them for me!! I am in bed for my daily rest!
This morning we took the kids to a holiday cookie baking and magic show (the magician didn't show up though), it is at L's school so we walked. I walked with 2 crutches but left 1 in the stroller when we got there. Later we went out for pizza and I took one crutch. I get tired after a while, that's why in the house I was ok, I wasn't going very far in one stretch.
But it is so nice to be home, like any good Jewish family, there are always in-law issues, sibling issues and plenty of food! I have never eaten so much dessert before, hopefully my body needed all those extra calories to heal!
I return to PT tomorrow, I am not sure if I will go more than one time this week. Dr. Kelly wants me to take it slow, and it is Jk's birthday on Thursday, we are going to see Playhouse Disney Live! I will let P check my ROM and see what he thinks. Extension is going to be my biggest issue this time around I think, and I am developing some trochnateric bursitis, I think. I am still awfully bruised on the trochanter and medial to the incisions. It makes me wonder if they ever found the cushioning device that was 'missing' pre-op. L says my femur is very purple. Yes, she says femur. She is very into anatomy, and at 3, it i impressive, She knows the following bones: Scapula, clavicle, humerus, radius,ulna, phalanges, femur, patella, tibia, fibula, calcaneus. She loves medical dramas as well. We watch House, Grey's Anatomy, Private Practice and Scrubs.
I have some cute pics, we have a new camera so I will try to get J to upload them for me!! I am in bed for my daily rest!
Tuesday, November 13, 2007
Details, Details,Details Part 2
As promised, here is the rest of the 'story'.
So the last thing I remember is the anesthesiologist asking me to sit up and then passing out. I am really scared of spinal needles, I have horrific memories of the pain of the spinal before my c-section and the epidural during childbirth with Jk, I like that I was out fr it during my first 2 scopes and wanted the same this time.
I was awakened in the OR, I think, and I asked what time it was, someone said 10:30, and then I fell back asleep. I remember waking up in the PACU again, maybe Dr.Kelly had come to speak to me as I really made it clear that I wanted to speak with him before going home. He had told me to make sure not to leave, plant my feet and don't move, until he came out of surgery!!! He tried to show me the scope pics and some x-rays, but seriously, he could have been telling me about the football game from the day before, he did say something about scar tissue and the cam bump, then I fell asleep. My spinal began wearing off and my pain was bad. I was given some Dilaudid, I slept some more. Then the PA from pre-op came to check on me, I remember saying 'I need pain meds', which got everyone jumping. The nurse said she had given me all the Dilaudid ordered, so did I want to try and eat something and take Percocet since she would have to ask the anesthesiologist if I could have more Dilaudid, and he was in surgery. I'm sure by now you can guess what my response was: "Page Him." So she did, and I got my drugs! I slept more, and more. I think I ate some crackers at some point and drank some gingerale to take the Percocet, then I slept more, I was really really lightheaded and dizzy. I don't remember if I got more Dilaudid after that. Dr. Kelly came back again, he asked if I remembered speaking to him earlier, I said yes, but I didn't remember what he said. HE told me again...took down the cam, scar tissue, and the psoas was fine 'you were right, I'm glad I listened to you.' He also said had he done my left hip first, he would have done the same on the right, cam and pincer in one shot. I asked, 'so I am not crazy', to which he replied 'that I can't say!' While he was there, he checked my dressing and decided to change it bc my incisions had ozzed I guess, I was in no condition to really care though. The nurse also requested he order more fluids since I had all that Dilaudid.Then I fell asleep again.I just couldn't stay awake but I really wanted to get out of there and go home. I finally called over my nurse, who btw, was incredible, she took great care of me! I told her to get me up, I want to go home! she asked if I was sure, she was nervous bc I was so lightheaded. I said we'll take it slow. So first she sat up the bed, then I sat on the edge for a while, I was close to the fine line between passing out and not, but I made it. She had to take out the epidural catheter from my back, then I transferred to a reclining chair on wheels. I was taken to the bathroom, you cannot be discharged without demonstrating that you can urinate. in the past, by the time I get out of bed, I am ready to explode, this time I wasn't, but I knew I had had a lot f fluid. I got to the bathroom and had no urge to go, but sort of forced myself to. I had a FULL bladder, so it was weird to not have any sensation. I mentioned it to the nurse but she thought nothing of it. The same happened when Jk was born...it resolved. I was then taken to Phase 2 of recovery where you get dressed and have PT. They left in my IV because I didn't look too hot! I now know the PT's and they were really nice to me. I got dressed and took a short trip around with my crutches and was allowed to be discharged! It was around 4:00 I think, surgery was at 8AM! There was another one of Dr. Kelly's patients in phase 2, he obviously had his surgery after mine since I was first, and we were being discharged at the same time! I would make a terrible drug addict, I would be too tired and sick to enjoy the high!! I guess that's a good thing. J picked me up in the car and we went to CVS for my drugs.
I made it into CVS but began feeling lightheaded, so I sat down. CVS was out of Percocet, I kid you not, and hadn't filled my Zofran bc it was for 20 pills but my insurance only covers 12. We got the 12 and went home sans Percocet, but I had some leftover from last time. Good thing I keep a nice stash!! I inhaled a Zofran in the car and made it home with no incident!
I spent most of the rest of the day in bed. I went to the bathroom shortly after arriving home, I looked at my leg, shit, the bandage had soaked all the way through with blood. This had never happened, I guess that's why he changed it earlier. I called and spoke with Dr. Kelly, he said to have J go buy gauze and tape, change the dressing and apply pressure. We changed it and I fell asleep. Arianna called around 9 to check on me, I think it had stopped bleeding, she said numb up my hip and sleep on that side to apply more pressure. It worked, it hasn't bled since.
I woke up around 10:45 needing a Percocet, J brought me some soup and I had the pill, was up for a bit and fell back asleep. I guess I am making up for all the nights the last few weeks. I no longer have anxiety, obviously it was over this, my blood pressure yesterday morning was 140/82, way too high for me!
I think we are in the clear, other than some serious butt pain from the traction, I have only surgical pain, no 'groin pain'. I will definitely keep you posted in my usual fashion!!!
So the last thing I remember is the anesthesiologist asking me to sit up and then passing out. I am really scared of spinal needles, I have horrific memories of the pain of the spinal before my c-section and the epidural during childbirth with Jk, I like that I was out fr it during my first 2 scopes and wanted the same this time.
I was awakened in the OR, I think, and I asked what time it was, someone said 10:30, and then I fell back asleep. I remember waking up in the PACU again, maybe Dr.Kelly had come to speak to me as I really made it clear that I wanted to speak with him before going home. He had told me to make sure not to leave, plant my feet and don't move, until he came out of surgery!!! He tried to show me the scope pics and some x-rays, but seriously, he could have been telling me about the football game from the day before, he did say something about scar tissue and the cam bump, then I fell asleep. My spinal began wearing off and my pain was bad. I was given some Dilaudid, I slept some more. Then the PA from pre-op came to check on me, I remember saying 'I need pain meds', which got everyone jumping. The nurse said she had given me all the Dilaudid ordered, so did I want to try and eat something and take Percocet since she would have to ask the anesthesiologist if I could have more Dilaudid, and he was in surgery. I'm sure by now you can guess what my response was: "Page Him." So she did, and I got my drugs! I slept more, and more. I think I ate some crackers at some point and drank some gingerale to take the Percocet, then I slept more, I was really really lightheaded and dizzy. I don't remember if I got more Dilaudid after that. Dr. Kelly came back again, he asked if I remembered speaking to him earlier, I said yes, but I didn't remember what he said. HE told me again...took down the cam, scar tissue, and the psoas was fine 'you were right, I'm glad I listened to you.' He also said had he done my left hip first, he would have done the same on the right, cam and pincer in one shot. I asked, 'so I am not crazy', to which he replied 'that I can't say!' While he was there, he checked my dressing and decided to change it bc my incisions had ozzed I guess, I was in no condition to really care though. The nurse also requested he order more fluids since I had all that Dilaudid.Then I fell asleep again.I just couldn't stay awake but I really wanted to get out of there and go home. I finally called over my nurse, who btw, was incredible, she took great care of me! I told her to get me up, I want to go home! she asked if I was sure, she was nervous bc I was so lightheaded. I said we'll take it slow. So first she sat up the bed, then I sat on the edge for a while, I was close to the fine line between passing out and not, but I made it. She had to take out the epidural catheter from my back, then I transferred to a reclining chair on wheels. I was taken to the bathroom, you cannot be discharged without demonstrating that you can urinate. in the past, by the time I get out of bed, I am ready to explode, this time I wasn't, but I knew I had had a lot f fluid. I got to the bathroom and had no urge to go, but sort of forced myself to. I had a FULL bladder, so it was weird to not have any sensation. I mentioned it to the nurse but she thought nothing of it. The same happened when Jk was born...it resolved. I was then taken to Phase 2 of recovery where you get dressed and have PT. They left in my IV because I didn't look too hot! I now know the PT's and they were really nice to me. I got dressed and took a short trip around with my crutches and was allowed to be discharged! It was around 4:00 I think, surgery was at 8AM! There was another one of Dr. Kelly's patients in phase 2, he obviously had his surgery after mine since I was first, and we were being discharged at the same time! I would make a terrible drug addict, I would be too tired and sick to enjoy the high!! I guess that's a good thing. J picked me up in the car and we went to CVS for my drugs.
I made it into CVS but began feeling lightheaded, so I sat down. CVS was out of Percocet, I kid you not, and hadn't filled my Zofran bc it was for 20 pills but my insurance only covers 12. We got the 12 and went home sans Percocet, but I had some leftover from last time. Good thing I keep a nice stash!! I inhaled a Zofran in the car and made it home with no incident!
I spent most of the rest of the day in bed. I went to the bathroom shortly after arriving home, I looked at my leg, shit, the bandage had soaked all the way through with blood. This had never happened, I guess that's why he changed it earlier. I called and spoke with Dr. Kelly, he said to have J go buy gauze and tape, change the dressing and apply pressure. We changed it and I fell asleep. Arianna called around 9 to check on me, I think it had stopped bleeding, she said numb up my hip and sleep on that side to apply more pressure. It worked, it hasn't bled since.
I woke up around 10:45 needing a Percocet, J brought me some soup and I had the pill, was up for a bit and fell back asleep. I guess I am making up for all the nights the last few weeks. I no longer have anxiety, obviously it was over this, my blood pressure yesterday morning was 140/82, way too high for me!
I think we are in the clear, other than some serious butt pain from the traction, I have only surgical pain, no 'groin pain'. I will definitely keep you posted in my usual fashion!!!
Details, Details,Details
I am in bed, took a Percocet about an hour ago. No one else is up in my house yet so there is no point in geting out of bed.
I had to be at HSS at 5:45AM. I had already filled out the majority of the paperwork last week, so I waited. In the meantime, I met the people from the magazine who were doing the photoshoot. They didn't call me in until after 6:30. I had to take a pregnancy test (negative, phew), and put on one of their cool hospital gowns with the heater attachment, and the 'hip scope breakaway' shorts! The camera crew came in to take some pre-op pictures. The PA came to do his mini pre-op physical around 7, 7:15. J was still in the waiting room. I was getting nervous bc in the past, everything has been done by 7, but hey, it wasn't like they were going to start surgery without me, right!
Next came the woman who washes the surgical body part, so she washed my hip. Then J was allowed to come in and we hung out for a bit.
Anesthesia came next. It was not Dr. Jules, the one I had requested. But I remember Dr. Kelly reminding me that all the anesthesiologists are great, so I was ok.He asked if I had had issues with anesthesia in the past. I explained that when I had a spinal with scope #1, it took me a long time to recover, so scope #2 was done with a combined spinal epidural, much better. So he said he would plan on that.
The nurse was next, almost 7:45, we were running out of time. She had to go over my medical history again, then start the IV. She wanted my to lay down, I assured her I wouldn't pass out, but she insisted.
While she was doing her thing, Dr. Kelly showed up to 'sign' my hip. I asked him to please write 'do not release psoas', in case he forgot! He said he would remember, and wanted to know if I was going to have the psoas police in the OR!! He even showed me the consent form, he said 'look, it is not even on here', so I said 'good, bc I don't consent'. I asked if I am his biggest pain in the ass patient, he said not even close, I just know too much. I didn't have a response bc just at that second, the nurse inserted the IV needle which silenced me! He said he was just going to go in and remove scar tissue, adesions and obviously the cam bump. Ok, fine,I could deal with that.
The OR nurse came next.She looked at my hip brace and asked where the rest of it was? Huh, thats all I have. What about the posts and pillow?Huh?? That's all they gave me. So off she went, super annoyed, to find whatever it was that was missing (I still am not sure). she came back to bring me to the OR, 'we are 5 minutes behind' she said. I left J, and we went to the OR. We passed someone who was looking for whatever it is she was missing.He said 'I told Dr. Kelly', to which she got clearly annoyed and said 'don't tell Dr. Kelly'. I assume they found it bc we proceeded into the OR. The camera crew was in there with someone showing them all the scope tools, I was trying to get a glimpse, but they needed to get the anesthesia going. I was laying on the table and the anesthesiologist gave me something to relax me, and asked if I could sit up,I told him I didn't want to feel the needle go in, he told me he would make my skin numb, and then I was out!
Part 2 to follow after coffee!
I had to be at HSS at 5:45AM. I had already filled out the majority of the paperwork last week, so I waited. In the meantime, I met the people from the magazine who were doing the photoshoot. They didn't call me in until after 6:30. I had to take a pregnancy test (negative, phew), and put on one of their cool hospital gowns with the heater attachment, and the 'hip scope breakaway' shorts! The camera crew came in to take some pre-op pictures. The PA came to do his mini pre-op physical around 7, 7:15. J was still in the waiting room. I was getting nervous bc in the past, everything has been done by 7, but hey, it wasn't like they were going to start surgery without me, right!
Next came the woman who washes the surgical body part, so she washed my hip. Then J was allowed to come in and we hung out for a bit.
Anesthesia came next. It was not Dr. Jules, the one I had requested. But I remember Dr. Kelly reminding me that all the anesthesiologists are great, so I was ok.He asked if I had had issues with anesthesia in the past. I explained that when I had a spinal with scope #1, it took me a long time to recover, so scope #2 was done with a combined spinal epidural, much better. So he said he would plan on that.
The nurse was next, almost 7:45, we were running out of time. She had to go over my medical history again, then start the IV. She wanted my to lay down, I assured her I wouldn't pass out, but she insisted.
While she was doing her thing, Dr. Kelly showed up to 'sign' my hip. I asked him to please write 'do not release psoas', in case he forgot! He said he would remember, and wanted to know if I was going to have the psoas police in the OR!! He even showed me the consent form, he said 'look, it is not even on here', so I said 'good, bc I don't consent'. I asked if I am his biggest pain in the ass patient, he said not even close, I just know too much. I didn't have a response bc just at that second, the nurse inserted the IV needle which silenced me! He said he was just going to go in and remove scar tissue, adesions and obviously the cam bump. Ok, fine,I could deal with that.
The OR nurse came next.She looked at my hip brace and asked where the rest of it was? Huh, thats all I have. What about the posts and pillow?Huh?? That's all they gave me. So off she went, super annoyed, to find whatever it was that was missing (I still am not sure). she came back to bring me to the OR, 'we are 5 minutes behind' she said. I left J, and we went to the OR. We passed someone who was looking for whatever it is she was missing.He said 'I told Dr. Kelly', to which she got clearly annoyed and said 'don't tell Dr. Kelly'. I assume they found it bc we proceeded into the OR. The camera crew was in there with someone showing them all the scope tools, I was trying to get a glimpse, but they needed to get the anesthesia going. I was laying on the table and the anesthesiologist gave me something to relax me, and asked if I could sit up,I told him I didn't want to feel the needle go in, he told me he would make my skin numb, and then I was out!
Part 2 to follow after coffee!
Monday, October 8, 2007
I Almost Forgot
As I was writing earlier tonight,I kept thinking that there was something I wanted to tell you but I couldn't remember. As I lie in bed at 11:30, it just hit me.
Dr.Millis' office called me this morning. He reviewed my films and said I should stick with a scope with Dr. Kelly. So now, one less thing to worry about!
Dr.Millis' office called me this morning. He reviewed my films and said I should stick with a scope with Dr. Kelly. So now, one less thing to worry about!
Tuesday, September 25, 2007
Too good To Be True
I do not have a date set for my injection. When someone actually called me to schedule it, I was shocked. Having not heard back from them with a day and time is more the norm. I will see what tomorrow brings.
I feel like I have finally "made it" in this world!!!
I have a feature on Google called 'Google Alert", I type in certain keywords or topics, and whenever a new webpage comes up in Google with these words, I receive an email with the link. Today, I received an email for my Google Alert keyword 'hip arthroscopy', guess what the webpage was? MY BLOG!!!
I feel like I have finally "made it" in this world!!!
I have a feature on Google called 'Google Alert", I type in certain keywords or topics, and whenever a new webpage comes up in Google with these words, I receive an email with the link. Today, I received an email for my Google Alert keyword 'hip arthroscopy', guess what the webpage was? MY BLOG!!!
Monday, September 24, 2007
Second Opinion (A good place to start if you have just joined me on my adventure)
Here is what I wrote in the letter for my second opinion:
Thank you for taking the time to review my films/ reports. Enclosed you will find radiology reports, operative reports and office notes from Dr. Kelly, as well as my MRI’s, x-rays and CT scan on CD. I would like to consult with you regarding my right hip. Below is a brief history of my problem.
I am a 27 year old physical therapist, mother of 2. I began having right hip pain in November 2006. At the time, physical therapy did not help and I decided to consult with Bryan Kelly at HSS in January 2007. I had positive impingement signs and clicking in the hip, as well as pain with resisted hip flexion. Dr. Kelly ordered an MRI which showed cam impingement and a labral tear. An intra-articular injection of marcaine/ kenalog/ cortisone initially relieved all of my pain. We decided to do an arthroscopy to address these issues, on March 5, 2007. The scope addressed pincer impingement and debrided the labral tear.
I was doing very well after that surgery, with the exception of some residual pain at end range hip flexion, and flexion with adduction and internal rotation. Additionally, my left hip began bothering me during the period of time that I was partial weight bearing, and I had identical symptoms on the left as I had pre-op on the right. We decided on another scope, July 2, 2007. Four days before the surgery on the left, I had a twisting injury on the right side, I was weight bearing on the right and turned to the left, at that time, I heard and felt a pop, and had severe pain. The pain persisted for the entire day and subsided slightly over the next few days.
On July 2, I had the left hip scoped. The scope addressed cam and pincer impingement and debrided the labral tear. The left side is doing well. The right side continued to bother me after the left scope, being on crutches exacerbated that side and all of my pre-op symptoms returned.
Towards the end of July, I contacted Dr. Kelly regarding my symptoms as I was extremely concerned that I had possibly re-torn my labrum. He ordered an MRI, followed by an intra-articular injection which gave me complete pain relief. I have been very concerned about the cam impingement remaining in my right hip. He also ordered a CT scan. At this point, Dr. Kelly has suggested a revision arthroscopy to address the cam bump, and possibly address the psoas, as he feels I injured it when I twisted that hip. I will be having the psoas injected in the coming weeks to determine if it truly is an issue or not.
At this point, I am unsure of how to proceed. I am skeptical of having another arthroscopy since the first one was not able to fully address my impingement. I am writing to you to see if you think my impingement would be better treated via an open procedure, and to see whether you think I should make an appointment to see you in person.
Again, thank you for the taking the time to read this and review my file.
If you have any question, please feel free to contact me at (phone #), or via email (email address)
Sincerely,
Susie
Thank you for taking the time to review my films/ reports. Enclosed you will find radiology reports, operative reports and office notes from Dr. Kelly, as well as my MRI’s, x-rays and CT scan on CD. I would like to consult with you regarding my right hip. Below is a brief history of my problem.
I am a 27 year old physical therapist, mother of 2. I began having right hip pain in November 2006. At the time, physical therapy did not help and I decided to consult with Bryan Kelly at HSS in January 2007. I had positive impingement signs and clicking in the hip, as well as pain with resisted hip flexion. Dr. Kelly ordered an MRI which showed cam impingement and a labral tear. An intra-articular injection of marcaine/ kenalog/ cortisone initially relieved all of my pain. We decided to do an arthroscopy to address these issues, on March 5, 2007. The scope addressed pincer impingement and debrided the labral tear.
I was doing very well after that surgery, with the exception of some residual pain at end range hip flexion, and flexion with adduction and internal rotation. Additionally, my left hip began bothering me during the period of time that I was partial weight bearing, and I had identical symptoms on the left as I had pre-op on the right. We decided on another scope, July 2, 2007. Four days before the surgery on the left, I had a twisting injury on the right side, I was weight bearing on the right and turned to the left, at that time, I heard and felt a pop, and had severe pain. The pain persisted for the entire day and subsided slightly over the next few days.
On July 2, I had the left hip scoped. The scope addressed cam and pincer impingement and debrided the labral tear. The left side is doing well. The right side continued to bother me after the left scope, being on crutches exacerbated that side and all of my pre-op symptoms returned.
Towards the end of July, I contacted Dr. Kelly regarding my symptoms as I was extremely concerned that I had possibly re-torn my labrum. He ordered an MRI, followed by an intra-articular injection which gave me complete pain relief. I have been very concerned about the cam impingement remaining in my right hip. He also ordered a CT scan. At this point, Dr. Kelly has suggested a revision arthroscopy to address the cam bump, and possibly address the psoas, as he feels I injured it when I twisted that hip. I will be having the psoas injected in the coming weeks to determine if it truly is an issue or not.
At this point, I am unsure of how to proceed. I am skeptical of having another arthroscopy since the first one was not able to fully address my impingement. I am writing to you to see if you think my impingement would be better treated via an open procedure, and to see whether you think I should make an appointment to see you in person.
Again, thank you for the taking the time to read this and review my file.
If you have any question, please feel free to contact me at (phone #), or via email (email address)
Sincerely,
Susie
Saturday, September 1, 2007
Thats what friends are for....
As I have previously mentioned, I got together this week with my 'hip friend' Amy, who has had her left hip scoped twice by Dr. Kelly and will be having her IT band released in the next few weeks/ months. I asked her to write a guest blog post.
Susie asked me to write a guest spot for her blog.... Hmmmm.. what to say?!?! I met Susie as a result of posts on the labralicious and FAI listserves. We had been talking as she had decided to see Dr. Kelly and I had experienced surgery with him. We talked quite a bit on-line and by phone. When I flew up to NYC on March 21st, the day before my surgery, we decided to meet. Needless to say, we clicked. My ride home to my friend's apartment in the city fell through because of complications with getting my surgery started, and Susie came to my rescue just two weeks after her own surgery. She drove in to New York Presby to pick me up and take me to my friend's place. Of course, meeting her two adorable kids in the car on the way home from the hospital sealed the deal!! We are forever "joined at the hip!" On my next trip up, we met and went to the Central Park Zoo together. I had a blast with Susie and her kids and it was a welcome afternoon of fun for both of us. Being able to jump in puddles with L and JK was the highlight of my day!! As a result of meeting on the listserves, we have become friends with this horrible hip problem in common. We have been through each other's ups and downs and frustrations. .... and the "emotionally unstable:" e-mail subject line on multiple occasions. It is wonderful to have the support of someone who is going through the same thing... and with the same doctor. It also doesn't hurt that she is a PT either, and I have picked her brain on multiple occasions!!! This last trip up was just as much fun as it was frustrating... I flew in to NYC on Tuesday afternoon and met up with Susie and the kids. We went to the swimming pool and chilled out for a while. I had a blast taking pictures of all of the kids at the pool, and it has cemented my feeling that maybe I should consider getting back into photography for a living... That evening, we went to see Xanadu with my best friend, Marni. The three of us had a blast at the show, but looked like the walking wounded headed away from the theater! But, for that 90 minutes that the show was on (with us seated on the stage), we were feeling no pain! Well, except for when one of the cast members hit me on the head with a rubber mallet! The frustrating part was the visit to Dr. Kelly. I hate waiting in doctor's offices. It seems like you wait for hours and then get to see the doctor for a few minutes. I think that Dr. Kelly really didn't want to deal with me, because Susie's appointment was 20 minutes after mine and he saw her before me!! He agreed that I need to have my IT Band released but that it should be done back home in Pittsburgh by Dr. Gruen as an open surgery because he has never done an IT Band as messed up as mine with a scope. At least he admitted to is limitations. That is a big thing for a surgeon. As you have already read in Susie's blog, he admitted to missing part of her impingement in the original surgery. We are in the same boat there, as he did not address impingement in my first surgery either. It is a very frustrating thing to deal with to say the least. I did have the opportunity to strangle him playfully when he mentioned our last "argument' over the phone and I was telling him that both of my hips hurt now!! So, for all of you who have wanted to strangle your doctor (Kelly or other) I did it for you too!! I had a happy mood swing that afternoon when I took L to Wave Hill for a "supermodel photo shoot." We had so much fun, and L posed beautifully for me. Her Mom never gets pictures like that... always the "cheese" face, never the cute stuff!! It ended too soon as I had to catch a flight home. It truly amazes me how friendships can develop out of adversity. Heck, I even told Susie that if she has to have another surgery and her Mom gets sick of being there I would come up and help her out. (Provided I am on my own two feet at the time.) After all, That's what friends are for!
Susie asked me to write a guest spot for her blog.... Hmmmm.. what to say?!?! I met Susie as a result of posts on the labralicious and FAI listserves. We had been talking as she had decided to see Dr. Kelly and I had experienced surgery with him. We talked quite a bit on-line and by phone. When I flew up to NYC on March 21st, the day before my surgery, we decided to meet. Needless to say, we clicked. My ride home to my friend's apartment in the city fell through because of complications with getting my surgery started, and Susie came to my rescue just two weeks after her own surgery. She drove in to New York Presby to pick me up and take me to my friend's place. Of course, meeting her two adorable kids in the car on the way home from the hospital sealed the deal!! We are forever "joined at the hip!" On my next trip up, we met and went to the Central Park Zoo together. I had a blast with Susie and her kids and it was a welcome afternoon of fun for both of us. Being able to jump in puddles with L and JK was the highlight of my day!! As a result of meeting on the listserves, we have become friends with this horrible hip problem in common. We have been through each other's ups and downs and frustrations. .... and the "emotionally unstable:" e-mail subject line on multiple occasions. It is wonderful to have the support of someone who is going through the same thing... and with the same doctor. It also doesn't hurt that she is a PT either, and I have picked her brain on multiple occasions!!! This last trip up was just as much fun as it was frustrating... I flew in to NYC on Tuesday afternoon and met up with Susie and the kids. We went to the swimming pool and chilled out for a while. I had a blast taking pictures of all of the kids at the pool, and it has cemented my feeling that maybe I should consider getting back into photography for a living... That evening, we went to see Xanadu with my best friend, Marni. The three of us had a blast at the show, but looked like the walking wounded headed away from the theater! But, for that 90 minutes that the show was on (with us seated on the stage), we were feeling no pain! Well, except for when one of the cast members hit me on the head with a rubber mallet! The frustrating part was the visit to Dr. Kelly. I hate waiting in doctor's offices. It seems like you wait for hours and then get to see the doctor for a few minutes. I think that Dr. Kelly really didn't want to deal with me, because Susie's appointment was 20 minutes after mine and he saw her before me!! He agreed that I need to have my IT Band released but that it should be done back home in Pittsburgh by Dr. Gruen as an open surgery because he has never done an IT Band as messed up as mine with a scope. At least he admitted to is limitations. That is a big thing for a surgeon. As you have already read in Susie's blog, he admitted to missing part of her impingement in the original surgery. We are in the same boat there, as he did not address impingement in my first surgery either. It is a very frustrating thing to deal with to say the least. I did have the opportunity to strangle him playfully when he mentioned our last "argument' over the phone and I was telling him that both of my hips hurt now!! So, for all of you who have wanted to strangle your doctor (Kelly or other) I did it for you too!! I had a happy mood swing that afternoon when I took L to Wave Hill for a "supermodel photo shoot." We had so much fun, and L posed beautifully for me. Her Mom never gets pictures like that... always the "cheese" face, never the cute stuff!! It ended too soon as I had to catch a flight home. It truly amazes me how friendships can develop out of adversity. Heck, I even told Susie that if she has to have another surgery and her Mom gets sick of being there I would come up and help her out. (Provided I am on my own two feet at the time.) After all, That's what friends are for!
Friday, August 10, 2007
Work Hardening
I can be one of those commercials they used to show on TV, persuading young girls not to get pregnant, I think it went something like "baby, it changes everything". Why am I saying this? I am in the hotel room trying to get Jk to take a nap, not enjoying the pool!! Thats ok, I was ready for a baby, or 2!! Actually, travelling with kids has its perks, we got to skip the whole security line in Newark, and got to go in the "special services" line at Immigration! I have even gotten away with 'breaking the law' numerous times. Since the initiation of the 'no liqiuds' rule, things have been a little difficult when travelling with the kids. Especially the 'no ice' rule. But we travel with tons of food and snacks and milk....so I always throw in a few bags of ice, whats the worst that can happen, they will throw them away. But no, I get special treatment. All you have to do is look at me at the end of the security line, 2 kids, 2 strollers, carseat, no one is wearing shoes (yes, L and Jk need thier shoes screened as well), a diaper bag, a rollaway bag, J and his stuff, plus J putting his laptop away, his belt back on and trying to reconfigure the strollers....I usually look a tad frazzled by this point. I think the TSA officials are usually afraid to even question what type of liquid is in the sippy cup, and heaven forbid try to take my ice, for fear that I may hurt them. In the past, they have pulled me aside and quietly said "I am letting you keep the ice bags but don't tell anyone". I tend to invoke unwarranted sympathy!! The same thing happenned when checking into the airport on Wed. J went to park and left me with the kids + 6 pieces of luggage + 2 strollers+ 1 car seat, but with all 4 passports. The agent allowed me to check J in, even though he wasn't there, plus didn't charge me for the 5 lbs of overweight luggage I had, and even lied to the baggage handler about having charged me!!
Ok, so that is a quick explanation of why I have time for a long post now! Since returning to work, my right hip has been painful, and in fact, working causes pain. One of the first things they teach you in PT school is not to hurt yourself while treating (of course, first they teach 'do no harm'). So having good body mechnaics is key. If I am working on ROM, lets say, I will stand with one leg in front of the other, and shift my weight front and back, using my whole body for the ROM, not just my arms. In theory, this is great, except now, my hip gets the brunt of the work and seems to be the weakest link in my body! Sometimes, I will get up on a treatment table for certain things, if I decide to sit back on my heels, I may see stars from the sheer amount of pain shooting through the joint. I am not sure what to do about it, clearly hurting my back or shoulder to compensate for not being able to use my hips is out of the question, as is not working. I have to experiment with shoe choice, I did not wear my Danskos this week everyday (I know, fashion cannot always dictate), and my ballet slippers offer no support whatsoever (but are so cute!).
There are certain cases that need PT and need work hardening, for example, people who lift heavy loads, or work heavy machinery, they need to be trained to safely resume their normal work activities. This is not something I specialize in, nor something my practice specializes in (except my boss, but he doesn't know what is going on!!!), and returning to work as a PT does not fall into the same category as training the UPS man to carry 100lb boxes!!
(I again apologize for the spelling, I will do a retroactive spellcheck when I return to NY)
Ok, so that is a quick explanation of why I have time for a long post now! Since returning to work, my right hip has been painful, and in fact, working causes pain. One of the first things they teach you in PT school is not to hurt yourself while treating (of course, first they teach 'do no harm'). So having good body mechnaics is key. If I am working on ROM, lets say, I will stand with one leg in front of the other, and shift my weight front and back, using my whole body for the ROM, not just my arms. In theory, this is great, except now, my hip gets the brunt of the work and seems to be the weakest link in my body! Sometimes, I will get up on a treatment table for certain things, if I decide to sit back on my heels, I may see stars from the sheer amount of pain shooting through the joint. I am not sure what to do about it, clearly hurting my back or shoulder to compensate for not being able to use my hips is out of the question, as is not working. I have to experiment with shoe choice, I did not wear my Danskos this week everyday (I know, fashion cannot always dictate), and my ballet slippers offer no support whatsoever (but are so cute!).
There are certain cases that need PT and need work hardening, for example, people who lift heavy loads, or work heavy machinery, they need to be trained to safely resume their normal work activities. This is not something I specialize in, nor something my practice specializes in (except my boss, but he doesn't know what is going on!!!), and returning to work as a PT does not fall into the same category as training the UPS man to carry 100lb boxes!!
(I again apologize for the spelling, I will do a retroactive spellcheck when I return to NY)
Sunday, August 5, 2007
Field Trip
I have been dreading today for quite some time now, J has had a business trip planned and is out of town, I am alone, with both kids, on a weekend! But they are now both in bed, asleep from their adventurous day!
We are going away this week, we have a wedding, Jk and L are walking down the aisle. L needed dress shoes, so I decided to be brave and take them both to the city. In my head, I was going to find a great parking spot, walk in, buy the first shoe she tried on, and be on my way! Again, I was way wrong!! Everything seemed to be going well, we found a parking spot 3 blocks away, and it was free! But the store was closed. The next closest store was 14 blocks away, and I did not have my double stroller. L was such a trooper and walked both ways without a single complaint! I did have to bribe her with ice cream, but she walked a total of 28 city blocks, and she is 3. That means I also walked a total of 28 city blocks, as I am writing this, I have no pain!
I did make an interesting discovery though. Since most of my readers are in similar situations as me, I have found us a wonderful solution for mobility. Since we are probably all on the younger side, because we did not opt initially for a hip replacement, looking cool is a big deal to us! Eventually, we will probably all need new hips, and begin to lose mobility. Rather than rely on a cane, walker or wheelchair, we can all buy this:
I saw a woman riding one in the city, either it needs a better braking mechanism, or she needed to learn to drive it, but with a little tweaking it can be the ride of choice for 'hipsters of the future'!
As I am moving forward, I used our treadmill today for the first time! The treadmill generated a huge argument in my household, I did not want it. I will never be able to run on a treadmill, for the rest of my life, if I want to preserve my ever so fragile hips!! I don't need a treadmill to walk, I walk outside...alot! J insisted that he would use the treadmill everyday, I insisted that he would not, and I would not, and it would become a clothes hanger. I was wrong. He uses it occasionally, I never have though, it came in the interim between my 2 surgeries. But today, I actually used it. No, I didn't run, or even jog! I used it for a total of 3 minutes and 41 seconds! I did my side squats on an incline on it! It really hurt my right hip, hence the short amount of time! But I plopped L in front of the TV to buy some time and do my exercises.
I came to a shocking discovery, I cannot do a straight leg raise on my operated leg. I know the protocol says no straight leg raises (SLR) for 4 weeks, tomorrow is 5 weeks, but I could not lift my darn leg. I finally squeezed hard enough, somehow pulled the femur in close to my body (or at least it felt like that) and lifted it a few inches. I will have my PT watch me do it this week and report on what he sees, since my account of it from the floor may no be so accurate. It also really hurt to even attempt a SLR. Prior to surgery, I could do no more than 5 or 10 without severe pain, my right leg can do 8-10 at a time, and then it gets weak and painful. Hopefully, in the near future, I will be able to do 20, consecutively!
We are going away this week, we have a wedding, Jk and L are walking down the aisle. L needed dress shoes, so I decided to be brave and take them both to the city. In my head, I was going to find a great parking spot, walk in, buy the first shoe she tried on, and be on my way! Again, I was way wrong!! Everything seemed to be going well, we found a parking spot 3 blocks away, and it was free! But the store was closed. The next closest store was 14 blocks away, and I did not have my double stroller. L was such a trooper and walked both ways without a single complaint! I did have to bribe her with ice cream, but she walked a total of 28 city blocks, and she is 3. That means I also walked a total of 28 city blocks, as I am writing this, I have no pain!
I did make an interesting discovery though. Since most of my readers are in similar situations as me, I have found us a wonderful solution for mobility. Since we are probably all on the younger side, because we did not opt initially for a hip replacement, looking cool is a big deal to us! Eventually, we will probably all need new hips, and begin to lose mobility. Rather than rely on a cane, walker or wheelchair, we can all buy this:
I saw a woman riding one in the city, either it needs a better braking mechanism, or she needed to learn to drive it, but with a little tweaking it can be the ride of choice for 'hipsters of the future'!
As I am moving forward, I used our treadmill today for the first time! The treadmill generated a huge argument in my household, I did not want it. I will never be able to run on a treadmill, for the rest of my life, if I want to preserve my ever so fragile hips!! I don't need a treadmill to walk, I walk outside...alot! J insisted that he would use the treadmill everyday, I insisted that he would not, and I would not, and it would become a clothes hanger. I was wrong. He uses it occasionally, I never have though, it came in the interim between my 2 surgeries. But today, I actually used it. No, I didn't run, or even jog! I used it for a total of 3 minutes and 41 seconds! I did my side squats on an incline on it! It really hurt my right hip, hence the short amount of time! But I plopped L in front of the TV to buy some time and do my exercises.
I came to a shocking discovery, I cannot do a straight leg raise on my operated leg. I know the protocol says no straight leg raises (SLR) for 4 weeks, tomorrow is 5 weeks, but I could not lift my darn leg. I finally squeezed hard enough, somehow pulled the femur in close to my body (or at least it felt like that) and lifted it a few inches. I will have my PT watch me do it this week and report on what he sees, since my account of it from the floor may no be so accurate. It also really hurt to even attempt a SLR. Prior to surgery, I could do no more than 5 or 10 without severe pain, my right leg can do 8-10 at a time, and then it gets weak and painful. Hopefully, in the near future, I will be able to do 20, consecutively!
Thursday, August 2, 2007
Incompetencies
I am now waiting to get my MRI results. Having experienced many times the way Dr Kelly's office staff works, I anticipate this to be a long and drawn out process. Nothing huge has ever happened with them, but so many little things, it makes you wonder.
-When I called to make my first appointment ever, the receptionist didn't want to give me one as my injury was not 'sports related'...how many of you actually tore your labrum playing sports? Luckily, I insisted on speaking with his PA who said "definitely come in"
-His PA called me with my first MRI results, I really wanted to speak with him, I left 2 messages....heard nothing, until I sent him an email, heard within 45 minutes (it was nice to bypass his office staff)
-When I was being discharged from the hospital after my first surgery, my Gameready was nowhere to be found...someone forgot to order it for me
-I scheduled my post-op appointment at the same time I scheduled my surgery, when I arrived at 12 days post-op, on crutches, brace, and soaked from an icy rain, I was informed that he was in his 'other' office, 2 blocks away. When I arrived there, they could not find my appointment for the day, and were unsure of what to do, as his schedule was booked. I informed the man at the desk that I was not leaving until someone removed my sutures!
-After my second MRI, it took 3 phone calls to get through to him to call me with the results
-I wanted a copy of the MRI report, it took 3 days to have it faxed over, and multiple phone calls
-Luckily, all of my pre-op requests for my second surgery went through, including time of surgery, anesthesia and post-op meds
-I am eligible for temporary disability, but your doctor must fill out some paperwork. His PA did it for me the first time, and there was no issue, this time, I specifically faxed it to her, but it was intercepted by his office manager, who called to ask me, 4 days post-op, when I was going back to work, so she would know how long to write on the form. I explained that I was hoping to be back in 4 weeks, but Arianna had filled it out for 3 months last time, so she should do the same, just in case 4 weeks was not enough. She answered me with a snotty "well, then we can fill out an extension". Why bother with more paperwork, just fill it out for 3 months, and we don't have to worry about it anymore. The story doesn't end here (are you surprised). In my fax, I had included a note that said please fax back to me. A fax never showed up at my office. So I called, sigh, they couldn't find it, so they 'must have' mailed it to me. It never showed up in my mailbox, sigh, so another phone call, I am going to fax it to you, again, please have it ready for me, I will be in the office tomorrow, to which I got a reply of "I will do my best", as opposed to "I am so sorry I never filled your request, it will be ready tomorrow". I arrived at the office, and it was ready, filled out for 4 weeks of disability. I did end up going back to work at 4 weeks, but, sigh, nonetheless!!
-To schedule my 3rd MRI, at first, they tried scheduling it in the wrong facility, then, gave me an appointment almost a week later. I ended up calling the MRI department and rescheduling myself.
-When I arrived for my MRI, they had forgotten to fax over the prescription
-2 weeks to get the message through to call me with my 3rd MRI results
-When I finally decided that I wanted an injection (right side, 6 months out), I left a message and the office manager called me to see "how she could help me", uh, not at all, please have the dr call me
-At the time of this post, almost 24 hours have passed since I called to have the dr office schedule my injection, waiting to hear back from them
-Another injection nightmare, when we decided to inject my psoas, I got a call from the receptionist early the next day, I was impressed, they took initiative. I told her when I wanted it, she said she would call back with a time. 2 days went by, I called her back, she was going to have the other receptionist call me bc she is actually the one who books it with the radiologist, another day, I called back and asked to speak with receptionist #2, she was surprised I was calling bc receptionist #1 told her she had called me and confirmed the appt. Plus it was the wrong date. She corrected the error, and I thought everything was all good. Until the radiologist called and left me a message saying he wanted to make sure I wanted the 'other' appt, bc there had been some reschedulings done, it worked out and I got the day I wanted.
-So...sigh, nothing huge, but a lot of little things which add up to a lot of frustration!
-When I called to make my first appointment ever, the receptionist didn't want to give me one as my injury was not 'sports related'...how many of you actually tore your labrum playing sports? Luckily, I insisted on speaking with his PA who said "definitely come in"
-His PA called me with my first MRI results, I really wanted to speak with him, I left 2 messages....heard nothing, until I sent him an email, heard within 45 minutes (it was nice to bypass his office staff)
-When I was being discharged from the hospital after my first surgery, my Gameready was nowhere to be found...someone forgot to order it for me
-I scheduled my post-op appointment at the same time I scheduled my surgery, when I arrived at 12 days post-op, on crutches, brace, and soaked from an icy rain, I was informed that he was in his 'other' office, 2 blocks away. When I arrived there, they could not find my appointment for the day, and were unsure of what to do, as his schedule was booked. I informed the man at the desk that I was not leaving until someone removed my sutures!
-After my second MRI, it took 3 phone calls to get through to him to call me with the results
-I wanted a copy of the MRI report, it took 3 days to have it faxed over, and multiple phone calls
-Luckily, all of my pre-op requests for my second surgery went through, including time of surgery, anesthesia and post-op meds
-I am eligible for temporary disability, but your doctor must fill out some paperwork. His PA did it for me the first time, and there was no issue, this time, I specifically faxed it to her, but it was intercepted by his office manager, who called to ask me, 4 days post-op, when I was going back to work, so she would know how long to write on the form. I explained that I was hoping to be back in 4 weeks, but Arianna had filled it out for 3 months last time, so she should do the same, just in case 4 weeks was not enough. She answered me with a snotty "well, then we can fill out an extension". Why bother with more paperwork, just fill it out for 3 months, and we don't have to worry about it anymore. The story doesn't end here (are you surprised). In my fax, I had included a note that said please fax back to me. A fax never showed up at my office. So I called, sigh, they couldn't find it, so they 'must have' mailed it to me. It never showed up in my mailbox, sigh, so another phone call, I am going to fax it to you, again, please have it ready for me, I will be in the office tomorrow, to which I got a reply of "I will do my best", as opposed to "I am so sorry I never filled your request, it will be ready tomorrow". I arrived at the office, and it was ready, filled out for 4 weeks of disability. I did end up going back to work at 4 weeks, but, sigh, nonetheless!!
-To schedule my 3rd MRI, at first, they tried scheduling it in the wrong facility, then, gave me an appointment almost a week later. I ended up calling the MRI department and rescheduling myself.
-When I arrived for my MRI, they had forgotten to fax over the prescription
-2 weeks to get the message through to call me with my 3rd MRI results
-When I finally decided that I wanted an injection (right side, 6 months out), I left a message and the office manager called me to see "how she could help me", uh, not at all, please have the dr call me
-At the time of this post, almost 24 hours have passed since I called to have the dr office schedule my injection, waiting to hear back from them
-Another injection nightmare, when we decided to inject my psoas, I got a call from the receptionist early the next day, I was impressed, they took initiative. I told her when I wanted it, she said she would call back with a time. 2 days went by, I called her back, she was going to have the other receptionist call me bc she is actually the one who books it with the radiologist, another day, I called back and asked to speak with receptionist #2, she was surprised I was calling bc receptionist #1 told her she had called me and confirmed the appt. Plus it was the wrong date. She corrected the error, and I thought everything was all good. Until the radiologist called and left me a message saying he wanted to make sure I wanted the 'other' appt, bc there had been some reschedulings done, it worked out and I got the day I wanted.
-So...sigh, nothing huge, but a lot of little things which add up to a lot of frustration!
Wednesday, July 18, 2007
Operative Report 7/2/07
Second Surgery
*these reports are dictated, therefore, some words are missing and or incorrect
After the patient was correctly identified in the holding area, she was brought to the operating room. Spinal anesthesia with combined epidural was administered. The left hip was prepped and draped in the usual sterile fashion.
The lateral portal was established under fluroscopic guidance and then a distal lateral accessory portal was established.
Arthroscopic examination demonstrated a large anterior superior labral tear with associated___________ lesion also evidence of a Cam delamination effect and associated synovitis.
At this point, a labral tear debridement was performed at the level of the affected tissue. A smooth contour was achieved to the anterior, inferior, and posterior superior labrum.
Then, the acetabular rim lesion was clearly identified and a rim decompression was performed to reestablish the normal contour of the femoral head and neck junction. At the completion of the rim decompression, a wide synovectomy was then performed using the Tac-S radiofrequency probe.
The cartilage on the femoral head and acetabulum within the joint were in good condition. the ligamentum teres was in good condition, as well. At this point, the scope was brought into the peripheral compartment and a Cam bump identified with clear synovial herniation and pitting.
The junction between the normal articular cartilage and the area where the impingement was occurring was clearly demarcated and a Cam decompression was performed using a 5.5 mm high speed bur. Re-contouring of the affected region was established with good reestablishment of the normal articular cartilage. At the completion of the Cam decompression, all bony debris was evacuated from the joint. No further pathology was identified.
The instruments were removed from the hip and the arthroscopy portals were closed with 3-0 nylon sutures. A "morphine" (should say marcaine) cocktail was placed into the joint. The wounds were cleaned and dried. Sterile dressings were applied. The patient was awakened from anesthesia and brought to the PACU having tolerated the procedures well.
*these reports are dictated, therefore, some words are missing and or incorrect
After the patient was correctly identified in the holding area, she was brought to the operating room. Spinal anesthesia with combined epidural was administered. The left hip was prepped and draped in the usual sterile fashion.
The lateral portal was established under fluroscopic guidance and then a distal lateral accessory portal was established.
Arthroscopic examination demonstrated a large anterior superior labral tear with associated___________ lesion also evidence of a Cam delamination effect and associated synovitis.
At this point, a labral tear debridement was performed at the level of the affected tissue. A smooth contour was achieved to the anterior, inferior, and posterior superior labrum.
Then, the acetabular rim lesion was clearly identified and a rim decompression was performed to reestablish the normal contour of the femoral head and neck junction. At the completion of the rim decompression, a wide synovectomy was then performed using the Tac-S radiofrequency probe.
The cartilage on the femoral head and acetabulum within the joint were in good condition. the ligamentum teres was in good condition, as well. At this point, the scope was brought into the peripheral compartment and a Cam bump identified with clear synovial herniation and pitting.
The junction between the normal articular cartilage and the area where the impingement was occurring was clearly demarcated and a Cam decompression was performed using a 5.5 mm high speed bur. Re-contouring of the affected region was established with good reestablishment of the normal articular cartilage. At the completion of the Cam decompression, all bony debris was evacuated from the joint. No further pathology was identified.
The instruments were removed from the hip and the arthroscopy portals were closed with 3-0 nylon sutures. A "morphine" (should say marcaine) cocktail was placed into the joint. The wounds were cleaned and dried. Sterile dressings were applied. The patient was awakened from anesthesia and brought to the PACU having tolerated the procedures well.
Operative Report 3/5/07
First Surgery
*these reports are dictated, therefore, some words are missing and or incorrect
After the patient was correctly identified in the holding area, she was brought to the operating room. Spinal Anesthesia was administered. She was placed in supine position on the traction table and approximately 10mm of traction was achieved across the femeroacetabular joint.
The right hip was then prepped and draped in the standard, sterile fashion. A lateral portal was established under fluroscopic guidance using the Seldinger technique, distal lateral accessory portal was then established.
Arthroscopic examination demonstrated some cartilaginous loose bodies within the joint and demonstrated a large anterior superior labral tear with an acetabular rim lesion and associated synovitis.
The tissue of the labral tear was of nonviable quality. At this point, a labral debridement was performed . Labrum was recontoured to a normal anterior inferior and posterior superior labrum. Acetabular rim lesion was clearly identified and then, using a 5.5mm high speed bur, the acetabular rim lesion was shaved down to remove the rim osteophyte.
At the completion of the acetabuloplasty and labral debridement, a wide synovectomy was performed using the TAC-S radiofrequency probe. All cartilagenous loose bodies were then removed from the joint. Remaining cartilage surfaces on the femoral head and acetabulum were in good condition. the ligamentum teres demonstrated no significant fraying.
At this point, traction was released. Suction was re-established. No further pathology was identified. The arthroscopy portals were closed with 3-0 nylon sutures and the wounds were cleaned, dried.
The bottom of the page says continued, but I do not have more!
*these reports are dictated, therefore, some words are missing and or incorrect
After the patient was correctly identified in the holding area, she was brought to the operating room. Spinal Anesthesia was administered. She was placed in supine position on the traction table and approximately 10mm of traction was achieved across the femeroacetabular joint.
The right hip was then prepped and draped in the standard, sterile fashion. A lateral portal was established under fluroscopic guidance using the Seldinger technique, distal lateral accessory portal was then established.
Arthroscopic examination demonstrated some cartilaginous loose bodies within the joint and demonstrated a large anterior superior labral tear with an acetabular rim lesion and associated synovitis.
The tissue of the labral tear was of nonviable quality. At this point, a labral debridement was performed . Labrum was recontoured to a normal anterior inferior and posterior superior labrum. Acetabular rim lesion was clearly identified and then, using a 5.5mm high speed bur, the acetabular rim lesion was shaved down to remove the rim osteophyte.
At the completion of the acetabuloplasty and labral debridement, a wide synovectomy was performed using the TAC-S radiofrequency probe. All cartilagenous loose bodies were then removed from the joint. Remaining cartilage surfaces on the femoral head and acetabulum were in good condition. the ligamentum teres demonstrated no significant fraying.
At this point, traction was released. Suction was re-established. No further pathology was identified. The arthroscopy portals were closed with 3-0 nylon sutures and the wounds were cleaned, dried.
The bottom of the page says continued, but I do not have more!
Monday, July 16, 2007
Learn From My Experiences/ Mistakes
-Listen to your body, if you think something is wrong, seek help
-Find a hip specialist, not one who performs hip replacements, but one who can address labral tears and FAI
-Nexcare waterproof bandages will keep your stitches dry in the shower for the few days you are not supposed to get them wet
-If you are using a GameReady, do not keep filling it up with ice and water, this is annoying, and difficult for the person in charge of doing it. Freeze 5-6 mini water bottles and put them in the GameReady with 2" of water, keep another 5-6 bottles in the freezer and keep switching them
-Ladies, accept the fact that you will not be able to shave your legs for several days
-Accept the fact that you will not be able to wash the bottom of your feet in the shower for several days
-Save your hands, get Millenial crutches
-Find a PT who can help you, will listen to you, and can provide you with "hands-on" treatment
-Find another person who has gone through a hipscope already, and milk them for info/ help (I can be reached via email at suzq613 at aol dot com)
-Don't let anyone tell you "its just a 'scope'", this is serious surgery, and a much longer recovery than your basic knee scope
-It is normal to feel like you are on an out of control roller coaster ride, physically and emotionally, no one will understand what you are going through, I hope you listened to my previous advice and found a "hip friend"
-If you are at all apprehensive about having an MRI, bring your own music, keep your eyes closed the entire time, and take slow deep breaths
-this list will be continuously updated as I inadvertently make more mistakes!
-Take Colace with your narcs, and if all else fails, ex-lax or dulcolax works like a charm!
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