goldman’s AchillesBlog

HA HA HA, JUST got “official” clearance from surgeon’s office to start driving again. Look out teenagers, here I come!

This is a continuation of sorts from my April 16 posting when at that time I was diagnosed with DVT. Last week I met with a vascular specialist at my hospital for an approximately two-week followup from the “incident” and to discuss the prescription of Xarelto and blood thinners in general.

Let me begin by saying that I had one of the most enjoyable visits to the hospital, any hospital ever. I was arriving yet again with my wife and 10-year old son in tow and some trepidation from the memory of my last Xarelto-based visit. Whereas the last visit involved several hours captive in the ER and my blood pressure sky high, this visit ended after 45 minutes with me feeling completely informed, my blood pressure at a cool 120/80, and reassurance that recovery was on track and we had made the best decision possible. My visit entailed meeting with Ann Pianca, a nurse practioner who was so knowledgeable about blood clots and the various prescription drug therapies, and so good at explaining them, that I was somewhat blown away. Made me think, “Man — if the doctors and surgeons at this hospital (Lahey Hospital in Burlington MA by the way) would only emulate Ann, Lahey would be number 1, rather than number 4, in the Boston area.”

My posts sometimes tend to the long side. For this reason I will cut to the chase for other blood thinner consumers or potential users reading this post that depending on your personal health history and body chemistry, if you are thinking about taking or are prescribed Rivaroxaban because you are a “good fit” for this medication– I can assure you that you have or will have made an excellent choice. So there you have it. If you want to exit this blog before getting drawn down the drain of my ramblings, do so now; I bear you no ill will, and wish you the speediest and nicest recoveries possible. I tip my hat and bid you adieu.

For those achillesblog gluttons of punishment that want to hear more, read on!

From the moment Ms. Pianca entered the examining room, to the moment we left I felt like I/we were being handled and informed by a real professional. She started out the conversation by advising us exactly how long we would be with her and what to expect from this visit. I interjected that my goals with the visit were three-fold: 1) To find out how long I would need to be on blood thinning medication, 2) Learn more about Xeralto, and 3) If I didn’t like what I heard to determine the fastest and most efficient means possible to switch medication.

Ann assured me that all my goals would be met, and more. She proceeded to outline the basics of the human circulatory system, explaining blood flow as we learned in high school and college anatomy classes. She explained why clots happen and how they are treated, the anti clotting mechanisms of Xeralto and Cumadin, since those are the two main thinning medications that are prescribed. There are several other medications, but some have more risky side effects, and/or are less well known. In any event for a person of my age (52) and health history (healthy except for the ATR and some previous high blood pressure and high cholesterol) those are the two choices. For people with more complicated situations, for example cancer, diabetes, older, etc. the other medications come into play.

One of my main concerns with Rivaroxaban is the known non-reversal component. This means that the anti-clotting features have no known way to be stopped. Where cumadin can be counteracted with vitamin K, Xeralto continues to work its “charm”. The implication is that if one is to suffer a traumatic injury while on Xeralto — one is going to bleed. The big concern is with internal injuries. This was the main reason I was planning on getting off Xeralto once I returned to driving. So I had been watching the calendar, relieving my wife of (some) of the many doctors and hospital visits that she has had to drive me to, and I figured that while I am non-driving less likely I will suffer a bleeding type injury. I had been thinking up to this point that I was going to switch to Cumadin, until I talked it out with Ann. It’s a bit complicated, and I will try to relay accurately what she told me, but the reader is advised with the usual caveats: do your own research, be your own best patient advocate, and make the decision that you feel most comfortable with. I can only relay my experience and contentment with sticking on Xeralto, but your situation may differ.

Anyway, back to the story about bleeding. Well it turns out that all the blood thinning medications (as far as I know this applies to all of them) have a half-life. Which means that the anti-clotting mechanism lasts only so long, at which point it needs to be re-inforced. By you guessed it - taking more medication Rivaroxaban has a half life of 5 to 13 hours in most people. The implication being that if you do suffer a serious injury - you only have to wait a few hours before the anti-clotting mechanism stops and you can be treated appropriately (e.g. surgery). Cumadin on the other hand, has a much longer half-life - something like 20 to 60 hours. Now cumadin can be counteracted with vitamin K, and this is where I lost Ann a bit. But the vitamin K can’t be administered right away, or its effects don’t take right away, I am a bit hazy on this point. Patients can be treated with plasma infusions, but there are some limitations there as well. The big concern with Xeralto is dealing with head and brain trauma. What I gathered from Ann is that is one risk that can not be circumvented by other means (I’m sure there are other bleeding risks too, but she focused on that one), but as she put it: “Be careful. Wear seatbelts. If you ski, wear a helmut and know that if you hit a tree, well hitting a tree is risky whether on blood thinners or not.”

One of the main benefits to Xeralto over Cumadin is that it’s chemical properties make it a much smoother release into a person’s system. It’s just a pill, once or twice per day, and requires no monitoring. Cumadin requires monitoring which means more visits to the clinic, to assess it’s effective level and the dosing can vary greatly between patients. So after all the discussion of the half lives issue, and ease of use of Xeralto I was whole heartedly convinced to stay the course. I will be on the medication for about three months, at which point I will return for an ultrasound and appointment. One thing that I was surprised to learn - regardless of the ultrasound in three months, I will be taken off the Xeralto. I’m not really sure what happens from there, because Ann told me that once a blood clot forms, it’s much more likely to get them again in the future. So I guess I’d be back on one of the medications if that were to happen.

We ended the visit with a discussion of compression socks - with her telling me that I would need to wear those for two years, once I get out of the boot. Unfortunately the socks are a bit pricey, and not all insurance covers them, and some people can’t stand to wear them regardless.

So that’s my latest clot club update, until around July 11. Happy Healing!

I think most everybody who reads or posts to this site who has suffered ATR injury will agree that the perception of time sometimes moves as if the hands of the clock are stuck in a giant bowl of thick goopy syrup. Notwithstanding that molasses is sweet it is a rather weak consolation considering how much of a PITA it is to lose use of a leg.

Now I didn’t really mean for this post to start out on the negative side, because the past week has been fine, pretty even keel. I’ve been periodically reading the posts on this site, and on a personal progression have been transitioning from PWB to almost FWB. Tomorrow is six weeks to the day post surgery. I’ve been splitting most of my walk time between one crutch and no crutch, but my heel hurts too much to be exclusively zero crutches. I am finding that the one-crutch “walk” is slower, but offers the ability to lighten the load on my injured side. The one sort of funny side effect is that I have almost tripped on my one crutch several times as I set it aside nearby in case I need it but then forget I have set it down. I guess it is payback for the many times I have almost tripped up my boy and my wife in the common spaces of our house

After reading about it on this site on Friday I immediately bought an Evenup shoe balancer and had it shipped expensive 2nd day so that it would arrive by Saturday. That turned out to be a good purchase and I have had it on my left shoe since receiving it.

Today I meet with Ortho surgeon to discuss progress and to find out why o why was I recommended to not get on an exercise bike for three weeks. So a blog would not be a proper blog without at least some (more) complaining I am mystified by that advice. Somebody, please clue me in as to why I am ok to put 90 pounds of force on my leg, albeit protected by a nice sturdy high-tech plastic boot, in a downward motion with thrusting force that sometimes ends in a stomp. And yet I should avoid sitting pleasantly on an indoor exercise bike and pedal for a few minutes? Oh come on get real people. Ok, enough complaining I’ll get that answer later today, time to move on.

On an unrelated note I am finding that as I heal it is getting more difficult to do the exercises. I am not sure why, because Lord knows I don’t need much more motivation to get better faster. I don’t drink. I don’t smoke. I don’t drive. Life’s pretty boring right now. But somehow I am finding that I have to push myself to do all the exercises. But then I guess that is part of the reason why the ATR happened in the first place. And as I type I realize that is the problem: the exercises to speed recovery ARE boring. Every single part of this recovery is boring. I mean what one wants to do is go fast. Run fast. Ride fast. Ski fast.

Oh well, at least molasses is sweet.

Today was a good day. It’s been four weeks three days since surgery. Seven weeks five days nine hours since injury, but who’s counting. Last night I got a rare seven hours of solid sleep, woke up, did some overdue work, then napped for another hour. Bliss. I am grateful for a good night’s sleep. Later in the morning I had my foot out of the boot elevating, then massaging it and doing the Ankle flexion and circles exercise. For the first time in seven weeks the foot felt normal for a time. I am grateful for that nice experience. My 10-year old son spent the first day of his April vacation working on a school project and other non-video game activities. I was amazed. I was happy. For bits of time I even forgot I was wearing a boot. I remember reading other blogs on this site about gratefulness. I can’t remember what they were grateful for but I am grateful for my family, and this day. Whoever invented elevating - I am grateful to that person or persons - elevating my leg for a few minutes at a time a few times a day really really helps and is easy to do. I am still worried about the DVT that was diagnosed on Tuesday. But for now I can not detect any side effects from the medicine. I have been trying to stretch my injured leg more, wiggling my toes more, trying to think positive thoughts about the blood clot going away. Tomorrow I go look to buy an exercise bike. But now, this moment right now, I am grateful for today.

This week, week 4 post op and PWB seemed to start out on decent footing, pun intended. That is until yesterday happened when my family and I spent 8 hours at the hospital, 5 of which were in the lovely ER.

I had been noticing some odd ropy swelling near and below my calf on the surgical side for a few days. But I was in the boot, splint, and casts so often the past 7 weeks that I wasn’t paying close enough attention. At first I thought it was “normal” fallout from allowing some nice guy to cut me with a knife and fix my shredded tendon. I had a little bit of pain in the calf, but I thought that was holdover from the two weeks unpleasant surgical splint which had a pokey edge at that spot. It finally dawned on me that I should check this out. One phone call to the triage nurse with me uttering the magic words: “I have some pain in my calf.”

With a slightly panicky sound in her voice the triage nurse informs me that I need to immediately get into the office for an ultrasound and evaluation. After a flurry of phone calls and some logistical help from my wife, we manage to get set up for scanning at the closer by facility that my surgeon is associated with. It’s nearing the end of the work day, so my wife hustles down to my work office, picks me up, and whisks me to the hospital. That’s the last time of the day that anything happens fast. After a long two or three hours waiting for ultrasound, the painless but ticklish procedure, and the consult of ultrasound guy with my Doctor, the ultrasound tech comes out and informs me I need to head over to ER. It’s about this time that my blood pressure starts rising.

“ER?” I say. Why is that — did you detect something? The Ultrasound tech mumbles something under his breath about needing a doctor to evaluate the results. Since it is already 6pm, and my surgeon has headed home, and the hospital day doctors have cleared out, the only doctor available is one in ER. The guy hands me a form as we arrive at ER and tells me to give it to the check-in gal. I am thinking, oh oh, this does not sound good. I look at the sheet of paper and there are three neat little check marks next to “DVT” line items.

ER is crowded. It’s a pretty good sized area, with a waiting room, and various examining rooms, hallways, and waiting rooms. It seems as if every room has people, multiple people it them. Family members, patients, etc. And the hallways are lined with hospital beds with several patients lying in them, waiting. Waiting for what I don’t know but my blood pressure rises some more.

After checking in I notice that the floor around the check-in desk is unusually slippery. I am in a wheelchair so no concern of falling or damaging my precious newly fixed tendon, but my hiking shoe and boot glide seamlessly over the surface as I push away from the desk. I have trouble getting the wheelchair to back up my feet are sliding so much. I mention this to the check-in nurses and they laugh and say, “Yeah, somebody else mentioned that too.” At this point my thoughts turn a bit towards the nasty with ideas like this running through my head: “Duh lady! Somebody old, and or infirmed might take a spill while checking in. Do you and the ER want to be sued?”

At this point I realize I have not peed in hours and desperately need the restroom. There is a huge guy in a hospital bed in the corridor completely blocking the restroom door. He gets moved for me, and I crutch into the restroom. It’s small and difficult to navigate, a bit dirty. I suddenly realize that we are in the “3rd world” part of the hospital.

More time passes and finally a qualified nurse brings me over for some questioning and vitals. She must feel relaxed around me, why I don’t know because I was pretty agitated, but she starts to complain about how far in outlying towns people were coming to be at that hospital. I suggested to her that maybe the people in ER had their regular doctors there, or like me had moved around a bit further and further afield to find affordable housing, but had kept their primary at the hospital. This did not placate her. In any event she took my blood pressure: 155/105. Now I know that’s a bit high, and if this had been 3 years ago I wouldn’t have thought too much about it since I do, or did have high blood pressure. But with my recent health and nutrition kick, losing some weight, dropping the alcohol (mostly, but not completely), ditching cigar use, I had managed to get my blood pressure down to a normal range of 120/80 confirmed by multiple tests and devices. So now I am looking unahappily at the numbers. She informs me that I probably do have a clot, and that hopefully I will be released with medication and not have to spend the night. Sigh. The blood pressure ticks up.

Unbeknownst to me it turns out that once you are in the ER (at least at my hospital) they are required to take your vitals every hour. So apparently after an hour (but if feels less) another nurse tech comes over. This time my blood pressure rings in at 177/110. I look at the numbers and then the tech. He mutters to himself: “that can’t be.” Turns to me and says, “let’s try again.” At first I am concerned that the numbers are going to only go up forcing them to go into some sort of emergency life-saving mode. I take a deep breath, and luckily the readings drop to 155/110.

Much more time passes. Some blood is drawn to “save time.” My wife and kid head to the cafeteria before it closes. More time passes. At some point I get tired of being in the wheelchair, get on my crutches and start heading for a padded chair. As I crutch by the check-in desk it happens: FLAM! My crutch hits the super-buffed-more-slippery-than-ice waiting room floor. I head down for a crash. Ah ha! But fall down, not me. I have two feet. Unfortunately one of them is the foot with my achilles repair, but this all happens in a flash. I plant my bad foot (luckily in Aircast boot) down hard. Pain surges into my foot and up my leg. F***K I exclaim. I manage to keep from crashing down. After regaining my balance and a kindly gentleman helping I GLIIIDE into a chair. I angrily look at the check in nurse and say: “Maam! I almost fell. Do something about that ungodly slippery floor already.” I check my Achilles and as far as I can tell: no re-rupture. Phew.

The wife and kid return and I angrily describe the incident. After a little while I go back to the desk and ask the gal if she’s called anybody. I calmly explain to her that if I fall and re-rupture my Achilles, I am suing the ER. She informs me that she has indeed called somebody, twice. Nobody ever arrives to de-slick that floor.

Finally I am wheeled in to the swipe-badge only part of ER where the real action is, and lots of beds filled with people. More time. Finally the ER Doctor comes over and confirms it’s a clot. Informs me of my options: Take anti-coagulant medication, or not. But really the “not” option is not an option, so I recommend you take the medication, since that’s your only choice other than very bad things happening. Choose between a) Cumadin, or b) the newer fangled Xarelto. At first I was going to go with the more well known Cumadin because of it’s better known ability to be reverted, in the event that I were to get in accident or internally bleed and therefore need to get my blood coagulating again. But we end up opting for the Xarelto because it requires less (none really) monitoring, thereby potentially saving my wife several extra trips driving me in the car every other day to have my Cumadin levels analyzed.

Another hour in the ER and finally the medication and prescription is actually delivered. The pill is about the size of 1/4 of a pea. I am now “laughing” inside. Eight hours for a tiny pill.

So now it is one day later and I have only taken three doses. So far no nasty side effects, but I am only at the very beginning and I am told that I might have to take this stuff for six months!

Anybody else on Xarelto?