Since I wrote my first article for this report in the summer of 1998, I have had a number of opportunities to write about the way you and your colleagues take care of people who have undergone total joint replacement surgeries. From wound care nurses and physical and occupational therapists in the field to the software vendors that help them track a patient’s progress, it is safe to assume that everyone reading this page has been directly or indirectly impacted by the dramatic increase in the total number of these surgeries.
Today, I find myself on the other side of the scalpel. I took detailed notes before, during, and after my own October 24 total knee replacement procedure. I trust I am not assuming too much that some readers will be interested in my experience.
Caveat: I realize my experience may not be typical. Working in home health for nearly 25 years probably gave me an advantage that most would not have. Still, it occurs to me that it may be a good idea for those in home health to give patients some of the inside information to which I had access. Who knows? Maybe some nurses and therapists will find something here they did not know about the joint replacement patient's experience.
-- Tim Rowan
I had been acquainted for several years with Ben, a physical therapist and owner of a small home health agency that specializes in physical therapy. His agency has a stellar reputation, a 4.5-star CMS rating, and more 5-star Google reviews than any of the other 43 certified agencies in town. I asked Ben which orthopedic surgeon he would go to if he needed total joint replacement. He did not hesitate with his recommendation and I did not hesitate to make an appointment with Dr. Feign.
X-rays convinced Feign my left knee was fully bone on bone and I was a good candidate for total replacement. “However,” he told me, “payers like to see less invasive, less expensive procedures tried first to be sure surgery is absolutely necessary.” He recommended an injection of hyaluronic acid, a gel that expands into the joint and provides relief for about six months. I was fine with that as I had a health plan that year with a $6,000 deductible but would be signing up with Medicare in five months. He also prescribed some outpatient physical therapy sessions, saying they would be useful both to prepare for surgery and to satisfy my insurance company.
The gel worked remarkably well. It took three to four weeks to take full effect but eliminated most of my pain for a time. It did not, however, increase my range of motion. The old college injury still imposed its limitations. A stationary bike proved doable and effective, as long as I didn’t mind the clicking sound that vibrated up to my shoulder with every pedal revolution.
2013 – 2017
Actually, exercise is an important part of this story. Something about turning 60 flipped a switch in my conscience. With a little encouragement from my adult children (OK, a lot of encouragement), I got into a regular routine with a trainer who emphasized flexibility and core strength rather than building muscle bulk. By the time I was ready to go under the knife, I had developed – and here I get to show off the words most readers already know but I had to learn – strong quads and hamstrings, and strength and flexibility in both my IT band and anterior tibialis. When I expressed some doubts about surgery, the outpatient PT laughed and said, “Anyone who rolls his IT band on a foam roller as often as you do is going to do fine.” Thank you, Greg the trainer.
Considering the normal recovery time and the active summer of traveling and hiking my wife and I had planned, I wound up not scheduling the surgery the day I received my Medicare card, instead putting up with a little pain as the gel wore off, until after the NAHC Annual Meeting in October. After one last session in the gym with Greg, I checked into the hospital on October 24. First, though, there were four more mandatory preparation activities.
In the hospital
I was fortunate that my surgeon is on the staff of an excellent hospital. Check-in was easy and warmed blankets over a skimpy hospital gown made the lengthy prep interview process tolerable. I had not been warned they were going to shave my knee from mid-thigh to mid-calf. I survived that ordeal but wondered why they did not offer me the anesthesia before handing a razor to that muscular CNA who appeared to be in a big hurry.
My surgeon showed up and asked me what I was there to have done. I knew he knew what he was going to do, and I knew that he knew that I knew it was a test, but I played along.
“You’re going to stick metal and plastic in my knee,” I quipped. “That’s what I thought,” he grinned, “but which knee?” I suggested he should cut into the hairless one with the nicks and razor burns. He agreed, and then signed his name right on the shaved area with a Magic Marker. It is hard to describe my feeling of relief that the odds of a life-changing mistake after I was anesthetized were significantly diminished.
The anesthesiologist appeared and described in great detail exactly how he was going to put me under. (What he did not mention was that he is not in my insurance network, even though the hospital in which he works is. I did not learn that until his super-sized bill arrived weeks later.) Back to the present. The smiling face of an anesthesiologist, viewed over the top of the mask he strapped onto my face, is the last thing I remember.
K-Day, Tuesday afternoon
I am told I was in the operating room less than two hours. I awoke in a private hospital room to find massive bandages encircling my knee and two tubes disappearing into my thigh, one to drip a nerve block, the other for a stronger local anesthetic. I laughed when someone asked if I wanted to order lunch, then went back to sleep. Before long, however, a physical therapist woke me up to say it was time for my walk. “My what?” Yes, she said, up and at ‘em. I made it to the end of the hall and back, then to my room for another nap. That evening, I was able to eat, and watch Game One of the World Series, sitting up in a chair. It would not be exactly accurate to say I felt no pain; "I felt no leg" better describes my first and only night in the hospital.
Apparently, anesthesia drugs take days, not hours, to wear off. Wednesday was a day of attempting to catch up on emails while barely able to focus. Then there was “Walk #2.” This time, I made a 360 degree trip around the entire ward. My PT was impressed; I was relieved when it was over. After a quick lesson in the PT gym on how to ascend and descend stairs, she cleared me to go home and the surgeon agreed. ("How did it go?" I asked Dr. Feign. "I don't remember; it must have been OK," he answered, in all seriousness.) They removed the compression machines from my calves and replaced them with the tightest thigh-high stockings I had ever seen. “They prevent blood clots,” I was told, which immediately shut up my complaints about how tight they were.
I have heard a lot over the years about hospital discharge planners who steer patients toward their owned or affiliated home health agencies. I did not have that experience. I had named Ben’s agency from the beginning and the discharge planner, who had my request in her Epic station, offered no argument. All that remained was to figure out how to get clothes on and get to the exit. Fortunately, I had help with both.
World Series Game 2
The company that rents the “IceMan” delivered my unit right to my hospital room. Remembering the advice I had been hearing from every PT, “ice is your best friend,” I had my brother-in-law driver fill it up and plug it in as soon as I negotiated the four steps from garage to kitchen (old knee leads going up, new knee leads going down).
Settled, iced up, and saturated with Oxycodone, I turned on Game Two, Dodgers vs. Astros. Fortunately, I subscribe to my local daily newspaper so I could read the re-cap in the morning. Apparently, Oxy makes one very sleepy. Before I nodded off, Bethany called to set my first in-home PT visit for the next morning.
The Home Health Experience
I know which EMR Ben's agency uses; I helped him pick it out. So I was on the alert to see how his PT used it for my OASIS assessment. She didn’t. I anticipated being put through the “OASIS walk.” I wasn’t. Bethany did, however, do a professional assessment, even though she did not write anything down. She watched me walk with my rented walker and told me I was doing it correctly. She measured my range of motion. I almost managed 90 degrees, which she explained was pretty good for day three. We walked around the house a bit while she watched me get in and out of bed and in and out of the bathroom. She talked about Oxycodone, especially the importance of taking it as scheduled and the side effects. Following her advice, I consumed large amounts of Miralax…to no avail, it turned out. (Instructions on the bottle say it should be taken once a day. Ignore that!)
Later that same afternoon, Ashli the OT dropped by. She also watched me walk around the house with the walker and said I should shower while she was there, waiting within earshot while I struggled through an activity of daily living that I had done by myself for 60 years. Don’t tell Ashli, but I stared at the shower chair for a minute and decided not to use it. Disobedient, I know, but I didn’t fall, not even close. Eventually, I returned the rented shower chair, unused.
My Slave-Driver PTA
On Friday, the real work began. Bethany assigned me to her physical therapy assistant, Jill. That day, followed by four visits the next week and three the week after, she stretched my range of motion from 90 degrees to 70, taught my daughter how to help me get those awful stockings on, walked me up and down the 13-step stairway to my basement, took me outside for a goal of an 1,100 foot walk through the neighborhood (I managed almost 1,600), and covered my leg with kinesthetic tape. I noticed that she did carry a tablet with her. She used the EMR to check her schedule before arranging each visit, but she took her notes on paper. Bethany joined her for a supervisory visit on my 5th session.
At the end of Jill’s seven challenging, expert visits, Bethany returned to evaluate me for discharge. Happy with my range of motion and stability, she said she had no doubts I was ready to graduate from in-home to outpatient PT. Still no software, still no obvious OASIS questions. I assume that was all done later; I hope it was all done accurately. Her farewell hug stopped me from asking any pointed questions.
In the middle of my home health episode, it was time for my two-week checkup with my surgeon’s PA. I found it just as difficult to get into the passenger seat of my car as it had been when I was driven home from the hospital 12 days earlier. I was concerned that the swelling and range of motion had not yet significantly improved, but my pain was greatly diminished, enough that I had been able to cross two milestones: from Oxycodone to Ibuprofen and from walker to cane.
I was still determined to walk into that appointment without either assistive device. With a little bit of a swagger, I strode from the waiting room to the exam room carrying the cane rather than leaning on it. The PA replaced my gauze bandage with a half dozen butterfly strips laterally across the incision and looked at me suspiciously when I asked if I could drive myself home. “Is it an automatic?” Yes. “Are you still taking Oxycodone?” No. “OK, since it was your left knee, I guess you can start driving again.” Freedom!
With ice still a constant companion, I got set up with twice-weekly outpatient sessions. They turned out to be more similar to my gym workouts with Greg than my exercises and strolls with Jill. Pushing through the pain on a stationary bike until the joint loosened up, kicking in four directions with an elastic band strapped to my ankle, standing on one foot with my eyes closed, and pushing against a heavily-weighted plate left me winded and exhausted, especially as they added weight to the plate every session. The welcome relief of ice for the final 10 minutes made the first 50 quickly fade from memory.
Here is the most important thing I learned. Full flexion, straightening the leg until the back of the knee touches the therapy table while lying on one’s back, is as important as it is difficult. It is so tempting to fall into the comfort of sitting with one’s knee slightly bent, or lie in bed with a pillow underneath, that it becomes a matter of will power to force oneself to practice flexion. The consequence of weak will power, they tell me, is that scar tissue will form in the slightly bent position and you will never be able to straighten your leg completely again.
PT Brad explained this to me as he literally forced my knee down to the table by leaning most of his weight on it. No amount of moaning convinced him to stop. “I’m trying not to fight against you but I’m afraid something bad is going to happen.” He was unmoved. “Nothing bad will happen. This is good for you.” I questioned whether he and I had the same definition of “good.”
This time I drove myself to the appointment and did not bring the cane. Dr. Feign took x-rays and proclaimed me another one of his successes. “You should come back again in another six weeks but, if you’re feeling OK, just call a week early and cancel. You’ll be fine.” I reminded him how much prep work I had done, rolling my IT band and strengthening my quads and hamstrings for four years. He agreed to share the bragging rights with me.
Having no clear idea last summer how long it takes to recover from total knee replacement, I took a gamble and accepted an invitation to deliver a speech to the Home Care Alliance of Massachusetts Financial Managers meeting in December, three days after my 6-week checkup. I made it. Even my first TSA encounter was relatively uneventful. I pointed to my knee, they routed me through the full-body x-ray machine, and sent me on my way. There was a little pain after standing and talking for an hour but far less than Brad jamming my knee into the table with all his might. Thanks to careful planning, I spent that night in a hotel with a well-stocked ice machine.
©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org