September 2010


[Note: This entry was actually written in Feb 2014. I changed the posting date to keep my blog entries in chronological order.]

by George Taniwaki

The PACU

When I awaken, I am laying in a gurney. Two nurses are helping me into a bed in a private room. The clock on the wall and my wife tell me it is just after 4 pm. I was put under anesthesia at about 9 am, so it has been over seven hours since my last conscious thought.

Why did my surgery take so long? I was expecting to be in the room by 2 pm. And where did the time go? Unlike waking up from sleeping, waking up from anesthesia gives no sensation that any time has passed.

I vaguely recall being wheeled into this room from the post-anesthesia care unit. But maybe I’m just imagining that. From my research, I know patients are taken to the PACU after surgery until the anesthesia and sedation wear off. And I know the PACU nurses won’t let patients be transported unless they are conscious, communicative, and stable. But I have no memory of leaving the operating room, of ever being in the PACU, or talking to anyone before being brought to my room. Apparently, anesthesia also induces a form of amnesia.

Pain control

I feel drowsy, disoriented, and very weak. It hurts to breathe or move. A nurse checks my wrist band, asks for my name and birthdate, and then introduces herself. She asks me to rate my pain on a scale of 1 to 10. I say 7. The pain is throbbing, but it is not unbearable. Is 7 too low a rating? I guess I have a very high tolerance to pain. And I’m not squeamish, either.

The nurse says I can administer morphine using the PCA pump. The pump is calibrated to provide a 0.5 mg dose into my IV catheter when I push the button. There is no background dosage, so if I don’t press the button, I won’t get any pain relief. She tells me to err on the side of pressing the button too often rather than holding back. I can’t OD because the device has a timer set so that the button is locked out for six minutes after each dose (for a maximum dosage of 5 mg/hr or 120 mg/day). A blinking light tells me when pressing the button will cause the pump to switch on.

I press the button. The blinking light goes out. I hear a beep followed by the pump whirr, but don’t feel any better. I can’t wait for the next six minutes to pass. This is going to be a long evening.

PCApump

PCA pump, notice the syringe containing the morphine is in a locked box to prevent tampering or theft. Image from Abbott Laboratories

Vital signs

After a few hours, I feel better. I notice that I have a large number of wires and tubes connected to me. The wires on my chest and arms are connected to a machine that monitors my vital signs including my heart function (pulse rate and electrocardiogram). A cuff on my arm automatically checks my blood pressure every few minutes. Other sensors measure my temperature and breathing. The machine has an LCD screen with readouts and blinking lights and a speaker that makes a soft beeping sound to tell me it is working.

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LCD panel of a vital signs monitor. Image from General Electric

Kidney function

I have a catheter in my arm connected to a 1-liter IV bag of lactated Ringer’s solution set to a very fast drip rate. It’s running about 1 drop every 1-1/2 seconds, which I estimate to translate to 250ml/hr. That’s a lot of liquid being added to my blood that my kidneys… er, my one remaining kidney has to filter out. But I won’t have to worry about having to get up every few minutes to pee. That’s because I have a Foley catheter attached to my bladder that drains into a graduated jug.

BladderScan

The BladderScan measures bladder volume and urine retention. Photo by Susan Wolcott

Each time the IV bag empties, a nurse comes in to replace it, measures the volume of urine in the jug and empties it. If the amount of urine in the jug is less than 250ml, then I am retaining fluids. That is a sign that my kidney is not able to handle the workload. (It’s my chemical engineering training that makes me think about the complex biological, chemical, and mechanical processes that drive the mass balance equations.)

As an additional check of my urine production, the nurse also uses an ultrasound device called a BladderScan to measure the size of my bladder and the amount of urine that remains in my bladder.

Oxygen

I have a nasal cannula providing supplemental oxygen to me. Since it hurts to breathe, I’m taking shallow breaths and the extra oxygen is welcome.

Food

It is now past 6 pm. I’m not very hungry, even though I haven’t eaten anything since breakfast yesterday. For my first meal in over 36 hours, I can only have clear liquids. Unfortunately, the room service kitchen is now closed, so the only items available are beef broth (which doesn’t have much flavor but too much salt) and for dessert a square piece of red-colored gelatin. Yum.

Sleep

I doze off and suddenly I am awakened by the sound of the monitor alarm beeping. A nurse rushes in to check on me. She adjusts my cannula and leaves. A few minutes later, the alarm sounds again. We decide the problem is apparently sleep apnea and that it is safe to reduce the sensitivity of the monitor so the alarm doesn’t sound unless I stop breathing for more than 30 seconds.

I find that pressing the button on the PCA pump even when it isn’t blinking gives me a sense of satisfaction. I soon realize that since the pump can only be activated manually, sleep will be difficult. Unless I stay awake all night and keep pushing the button, I can’t administer the morphine to ease the pain. My guess is what will happen is that I will eventually get so tired that I will fall asleep. Then the pain will wake me up and I will push the button. I’ll stay awake until the morphine kicks in, then fall asleep and start the cycle over again.

Later that night, that is exactly what happens. I wake up in uncomfortable pain, push the button, and try to go back to sleep. A few minutes later, I wake up again. Couldn’t a safe pain-killer regimen be developed that could be administered automatically so that the patient could avoid the restless sleep?

****

The story of my recovery at the hospital continues in an Oct 2010 blog post.

For more information on becoming a kidney donor, see my Kidney donor guide.

by George Taniwaki

It is still dark outside when my wife Sue and I leave home to go to the surgery pavilion at the University of Washington Medical Center. My check-in time is 6:15am and we left home at 5:30. We have both overestimate the amount of traffic on the 520 bridge this early in the morning. (There is almost none and even though I’m going 65 mph, it seems that what few cars there are, are all passing us.) We get to the hospital easily before 6am.

The receptionist pulls out my yellow chart. She takes the forms she needs and hands the rest back to me. I ask her if I’m scheduled for laparoscopic surgery or open surgery. She looks at a timesheet and states that it says I am scheduled for laparoscopic but the surgeon will confirm. I’m still hopeful about it. She has me fill out some additional forms and puts a wrist band on me. Sue and I take our seats and wait.

****

I am not a happy camper. I haven’t had anything to eat in over 24 hours or anything to drink since 11 pm last night. I’m also still feeling the effects of the bottle of magnesium citrate I drank yesterday afternoon and so have to take a trip to the restroom.

****

After about an hour in the waiting room, I hear my name called. An attendant ushers us to a pre-operative care unit (pre-op). A nurse explains that I can put my clothes and valuables in a garment bag and put on a gown, elastic calf compression socks, and non-slip booties. After I get into the gurney, she starts up a hot air blower that inflates a disposable air blanket. The flimsy blanket is surprisingly warm and comfy while the blower is almost silent.

I have to urinate, so I get up and find a nurse who directs me. But I can’t go, apparently there’s nothing left in me. Slightly embarrassed I get back in my gurney.

Suddenly the room becomes a hive of activity where a steady stream of people enter to check on me and my chart. First, a new nurse takes my vital signs, my BP is 128/90, which is really high for me.

Then the first nurse returns to check my wrist band. She asks me to spell my name and give my birthdate. She then takes a sheet from my chart. She asks me to describe in my own words if I know what procedure I’m about to receive. I say, “donor nephrectomy, right side, possibly using laparoscopic method.” But then I say, “Actually, those aren’t my words, they’re the surgeon’s.”

A phlebotomist takes some more sheets from my chart and takes several vials of blood. My guess is a last set of blood panels to compare to my baseline and a final HLA crossmatch test.

An anesthesiologist, who is not the same doctor who interviewed me two days ago, comes in to discusses my case. An anesthesiology nurse enters and inserts an IV catheter line in my left wrist. Some confusion develops because the anesthesiologist says he was told the surgery was laparoscopic and if I am undergoing open surgery I should get either an epidural or spinal.

The circulating perioperative nurse enters and reviews my chart.

PreOr

Anesthesiologist, anesthesiology nurse, and circulating OR nurse holding the all important chart. Photo by Susan Wolcott

The surgical resident appears and marks my right flank with his initials. He doesn’t know whether the surgery will be open or laparoscopic either. He tells the anesthesiology nurse to stop my IV until he has a chance to confirm with the surgeon, because I need to be coherent when the actual procedure is explained to me. He grabs the chart and leaves. A couple of minutes later he returns and says the IV can start because I’ve already signed the consent form for open surgery.

Finally, the surgeon shows up. Dr. Bakthavatsalam asks me how I am and checks my right flank. He confirms that he will be performing open surgery. He says that is better than starting with laparoscopic and then switching to open if he cannot reach the renal artery using the robot.

He tells the anesthesiologist that I won’t be needing an epidural or spinal. Everything is ready, so I am wheeled into the operating theater (OR). It is a large white room filled with people, bright lights, and equipment. Looking straight ahead I notice the OR doesn’t have a second floor balcony and windows for observers as is usually depicted in television shows. I turn my head to see what’s on the other side of the room and then, nothing…

For more information on becoming a kidney donor, see my Kidney donor guide.

by George Taniwaki

Well, this is the day. It’s 5:00am. I’m leaving in a few minutes to check in at the surgical pavilion at the University of Washington Medical Center to have my kidney removed (right donor nephrectomy). It’s the culmination of three years of waiting to find a program and a hospital to accept my offer of a kidney. I slept fine last night (except having to get up twice to go to the bathroom), but I’m a still a bit tired and a bit nervous.

****

Over the past several months, a lot of people have asked me how it feels to be a potential kidney donor. They want to know if I’m getting excited or if I’m scared. Some of the people asking me that are also donors themselves. In July, Angela Stimpson, who has a wonderful kidney donor blog called OK Solo, asked me if I was excited. My response to her then follows.

“…Anyway, I’m not excited yet. I guess part of it is because I’m not an excitable kind of guy. Another part is that I’ve been waiting so long that I’ve had time to read, think, watch YouTube videos, and write about what I’m doing. So most of the mystery is gone. And another part is that it seems so passive. It’s not like getting ready for a vacation, climbing Mt. Rainier, or running a marathon. There isn’t any planning or training involved. And once my big day arrives, the first thing that will happen is they’ll knock me out, so there won’t be anything to see or remember. (Too bad I can’t just have a local, just so I can stay awake and watch… Or maybe not, since I might ask too many questions and distract the surgeon.)

“I’m sure I won’t sleep well the day before my surgery, but other than that, I don’t expect much of an adrenaline rush. But afterwards, if I get to meet the recipient, that will be pretty emotional.

“Hoping you the best with your donor surgery (which with any luck will happen before mine)…”

[Incidentally, Ms. Stimpson’s donor surgery was Sep 21, so it did happen before mine.]

OKSolo Image from OK Solo

And I dug up another email exchange. This one with Cara Yesawich who donated a kidney on Apr 25 and has a lovely blog called Simply Cara. In early June (when my donor surgery was scheduled for Jun 29), she asked if I was getting excited yet. My response:

“Eh, no excitement yet. But I still have 3-1/2 weeks left to go.”

SimplyCara

Cara and transplant recipient Dan Becker. Photo from Simply Cara

Actually, maybe it’s a good thing that I don’t get too emotional. My original donor surgery was cancelled less than a week before the scheduled date. It would have been a lot tougher on me psychologically if I was heavily invested in completing it on that specific day. And if I was the nervous or superstitious type, maybe I would have taken it as an omen and cancelled the whole thing. Instead, I took it somewhat in stride and picked a new donor surgery date three months later.

****

Well, time to go. If you never see another post from me again, you’ll know why. Just kidding. (Though I guess it’s true. And not just today for me. It’s true every day and for every person you know, including yourself.) Life is precious and ephemeral. So do stuff now that makes it worthwhile. Don’t wait and regret what could have been.

For more information on becoming a kidney donor, see my Kidney donor guide.

by George Taniwaki

Yesterday, I had three meetings as part of my presurgical consult. My second meeting was with the living donor transplant coordinator, Kami Sneddon. She provides me with written instructions for two rituals I must perform over the next day prior to checking in for my kidney donation surgery. Then she walks me through the instructions. At the end of our meeting she thanks me for being a donor and says she will visit me after my surgery.

Day before surgery

5:30 am Eat light breakfast
6:00 am Start fast, no solid food or milk after this point
noon Drink 10oz (300ml) magnesium citrate and water
8:00 pm to midnight Drink 2 quarts (2 liter) water
10:00 pm Take shower using Dyna-Hex-4 and scrub brush
midnight No liquids after this point

Day of surgery

4:30 am Wake up, remember no food or water
4:45 am Take shower using Dyna-Hex-4 and scrub brush; afterwards do not use any body or hair grooming products
5:15 am Drive to the hospital, you must have a companion

Presurgical bowel cleansing

The first ritual is to ensure my digestive tract is empty before I undergo anesthesia. Today (the day before surgery), I have a light breakfast at 5:30 am. After that, I cannot have any solid food or milk until after my surgery. I can only drink clear liquids that have no caffeine. Water, apple juice, and fruit-flavored soft drinks are fine. No coffee, tea, colas, or orange juice. I didn’t ask about broths, but I won’t have any of that either.

I go to work in the morning, but come home at noon. That’s when I take my dose of magnesium citrate solution, a laxative. It is a non-prescription item that can be bought over-the-counter at any drug store. However, for convenience, Ms. Sneddon gave me a prescription that I filled at the hospital pharmacy.

Citroma

Swan Citroma. Photo by George Taniwaki

The pharmacist provided me with a 10oz (300ml) bottle of Swan Citroma (mmm, lemon-flavored). It’s priced at $6.50 plus tax, but the transplant center covered the charge. She told me that I should drink the whole bottle, about half at once, the other half a few hours later, and drink additional liquid if I’m thirsty. She also says the Citroma will go down easier if I refrigerate it and add a dash of salt if I’m not on a sodium restricted diet.

To remove the last bit of liquid in my bowel, I should have nothing to drink between midnight until after my surgery. To prevent dehydration though, I should drink two quarts (2 liter) of clear liquid between 8 pm and midnight.

Presurgical scrub

The second ritual I need to perform is to ensure my body (actually, the skin on my abdomen) is sterile. For this, Ms. Sneddon provided me with a bottle of Dyna-Hex 4, a bactericidal liquid soap containing chlorhexidine gluconate 4% solution.

DynaHex1

Dyna-Hex 4 antiseptic soap. Photo by George Taniwaki

I am instructed to shower the night before surgery using a liberal amount of this soap and scrub my body using a brush (actually, I used a fresh washcloth) from my neck down to my knees for at least 10 minutes. I should repeat this scrubbing and showering the following morning before coming to the hospital for my surgery.

Using antiseptic soap will reduce the chance of bacteria and loose flakes of skin entering my body and causing an internal infection. Ms. Sneddon also tells me that I should not shave or use any grooming products the morning I come in for surgery since these can also enter my body and either irritate or infect me.

For more information on becoming a kidney donor, see my Kidney donor guide.

[Update: Added table describing the rituals to be performed the day before surgery.]

If any of you use Windows Live Spaces for your blog, and there must be at least one other person on Earth besides me who does, then you’ve had to tolerate some serious UI issues. For instance, sometimes the Live Spaces interface would appear in Spanish or another foreign language. Who knows why?

A major annoyance occurred a few months ago. The statistics feature, which is very important if you are trying to gauge the amount of traffic to your blog, was removed without notice or explanation. The feature didn’t work very well and was quite limited, but did they (the Windows Live team) have to kill it?

Another problem was the insert picture feature worked erratically. Sometimes high-resolution pictures would get downsampled before they were uploaded. Oftentimes, if you clicked on a thumbnail picture in my blog, it would display a pop-up of another image the same size and resolution as the thumbnail. I tried fixing it sometimes by editing the HTML by hand and uploading the high-resolution picture manually. But sometimes my manual coding wouldn’t work and I couldn’t figure out why. I also had a problem getting embedded videos to display and play.

Creating and editing tables was hard. I use a lot of tables in my blog. I coded my HTML tables by hand, which was tedious and error-prone. Finally, the trackback feature was completely overrun with spam while the comment feature had a CAPTCHA test that was so hard that nobody was leaving comments.

So what are the alternatives? Well, I like WordPress. If I had to do it again, I would probably use it. (I like Google Blogger too. However, as a Microsoft contractor I didn’t want to antagonize my coworkers by using a product from a direct competitor.)

Well, today, Microsoft has announced that it has thrown in the towel and is inviting all Windows Live Spaces users to switch to WordPress. My new blog will be located at https://realnumeracy.wordpress.com. I haven’t had time to migrate my content to this new site yet. I probably won’t be in the mood (or in a coherent state of mind) to do it until next week. At that time, I’ll provide a complete review of the migration tools to convert a Windows Live Spaces site to WordPress.

[Update: There is no transition “tool”. It’s just a one button step. And Live Spaces users have no choice. They must switch to WordPress or their blog will disappear at the end of the year.]

They are building a major addition to the Univ. Washington Medical Center. Up until today, the work has not affected access for people inside the existing building. But today, they are starting construction of the hallway that will connect the existing building to the new one. The main entrance to the Transplantation Services office is now blocked. Luckily there is a well-marked detour to get there. Just follow me.

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The main entrance to Transplantation Services is now closed.

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To get there now, just turn right before the blood draw and pharmacy…

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Past the information desk…

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Turn right at the financial aid office…

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Turn left at the end of the hall into an atrium…

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And finally, turn left at the end of the atrium.

Whew. (All photos by George Taniwaki)

Note: This is a continuation of my presurgical consult, part one here.

by George Taniwaki

After lunch, I go to the UWMC surgery pavilion to meet with an anesthesiologist for a pre-anesthesia clinic. I hand her my medical chart (see below). She picks out a form with a checklist of  medical questions and asks me to fill it out.

After reviewing my responses to the questionnaire, she reads through an extensive list of medicines asking if I am taking it or allergic to it. My answer is no” to every one. The reasons for these questions is to make sure that I’m not taking any meds that could interfere with anesthesia or would be dangerous in combination with it.

As I do at every other physical exam, I report that I have a functional systolic heart murmur. She asks about it. I say that I’ve had it since I was a child. She uses a stethoscope to listen to my heart and reports that I still have it.

She reviews my medical chart and asks why I came to UWMC on Sep 16, 2009 to get an ECG performed. I reply it was in preparation for this upcoming surgery. She says that was over a year ago and I may need another. She leaves the room to ask the attending physician. The answer is positive, so she hooks me up and gets a new reading. She prints out the old reading and compares them. They are nearly identical.

She asks me what I can tell her about my low WBC, low lymphocyte count, and low platelet count. (Incidentally, today’s WBC is 2.9, which is lower than any of my previous results.) I reply, “the low counts appear to be benign and that a bone marrow biopsy was clinically unremarkable.” I sound like a know what I’m talking about, but I’m just repeating the words of the hematologist at SCCA (see Jul 2009 blog post).

She seems satisfied and adds the results of the questionnaire to my chart.

SurgicalChart

My surgical chart. Photo taken on day of surgery by Susan Wolcott

She says that the exact time of my surgery on Wednesday will be set on Tuesday morning. Someone will call me that day (tomorrow) to tell me what time to check in. That’s a bit odd. I just assumed that I needed to check in at 6am and that the surgery would start at 9am. But I guess there is a chance that an urgent surgery could affect the schedule. I hope it doesn’t.

For more information on becoming a kidney donor, see my Kidney donor guide.

[Update 1: I receive a call on Tuesday afternoon. My surgery is scheduled for 9am, my check-in time is 6:15.]

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