The Athletics of Nursing

     On Monday, my brain activated the worry button when my surgeon updated my medical leave paperwork, changing the length of my estimated incapacitation from May 17th to June 20th. That makes sense. May 2 marks the point when I can begin weaning crutches and start gentle activity like walking in the pool or a recumbent bike with no resistance (as tolerated). 4 weeks later, I may begin PT.  So maybe that gives me 3 weeks of PT before returning to work for an injury that is known to take months to return to 80% of previous function.  With many jobs, this would be adequate. But there are days when my job as a Labor & Delivery nurse is an outright athletic event.
     When I was pregnant last year, there were days I could barely walk at the end of the day as my hips were expanding.  Just bending down to plug in a bed felt like a monumental task. And who designed those IV pumps we use? It was not a nurse who designed an IV pump that weighs 10 pounds plus up to four 2 1/2 pound pump modules added to make a 20 pound piece of machinery that you have to hold up isometrically with one hand for a solid minute or two while screwing in an extremely slow mounting clamp onto a pole...for almost every patient!
     Nurses are people movers. In Labor and Delivery, we move women with spinal anesthesia after a c-section, help women up to the bathroom the first time after epidural anesthesia, provide endless hours of counter pressure for labor support.  We twist, we turn, we bend, we lift, we sprint to emergency c-sections. Every once in awhile when I hear a colleague say "I really need to get back in shape!" I think, well, it can't be all that bad; you did just leap onto the bed pretty quickly to relieve that shoulder dystocia! And these activities go on for a 12 hour shift.
     To be clear, I am not complaining.  I am active. I love to move my body. I have loved that for the past 11 years (5 in Labor and Delivery), I have a job where I get to move my body in dynamic ways. I have worn the intensity like a badge of honor. I have kept myself fit so that I can effectively execute the demands of the job.
     The physical demand of bedside nursing is no secret. If you do a job search for nursing jobs at my hospital, any bedside nursing job states that you may have to do all kinds of physical movements including lifting 100 lbs.  Yes, it says that specifically: 100 lbs, though we move patients 2 to 3 times that weight! This is not like lifting 100 lbs at the gym. This is 100 lbs (or 250 lbs) that drops suddenly in a tight cramped space on a floor that maybe wet and slippery, as you are twisting your body around, banging your knee on a cabinet trying to figure out what the hell just happened.
     For the first time I have to worry that my body may not be able to meet the physical demands of a job I love and remain whole enough to keep up the other meaningful activities in my life. I cannot afford re-injury. When I went back to work after Emily was born, I cut back my hours substantially to 12 hours a week. How wonderful to spend more time raising my baby! But a 12-hr work week was the minimum my family could bear to keep our household a-float. As a part-time employee, that left me with no PTO (paid time off) and no disability insurance to help float us through this.  Add the medical bills to the mix and I am faced with a reality that I may need to go back to work full-time to recover from this injury financially.
     On the positive side, my hospital has a decent medical leave policy that does support keeping my job while incapacitated, even for part-time employees. My manager is supportive of my recovery and would love to bring me back when I am able. The questions is, can I afford to wait that long?

Gratitude

A friend of mine stopped by yesterday for a quick visit around lunchtime and made me a sandwich.  A little gesture that went along way.  I believe I illustrated the difficulty of taking things in and out of the refrigerator with 2 hands on crutches in a previous post.  As I told her my rehab plan and the length of time that I have to let the muscles in my left leg waste away, she commented:  "If your injury had happened to me, I don't know what I would do.  I have one tenth the support and close family network that you do!"
     It is true that a good chunk of my family lives in Salt Lake City. My sister, my parents, step-siblings and my husband's parents are all here. I have an aunt from Seattle who has flown out twice to help.  I am immensely grateful for the time and resources they have all pitched in to keep my household afloat!  But then more support popped out of the woodwork.  Friends brought meals. Since I can't be alone with now 1-year-old Emily, some have offered to stay with me for a few hours here and there. Friends and twice-removed family members have offered to transport Michelle to her various activities. One neighbor was so helpful to me one day, I actually hired her to help me for the next 6 weeks or until I am able go up and down stairs, perform light housework, and chase after my baby. All of these gestures large and small have accumulated into a network of support that was unimaginable the day of my injury.
     There is no doubt this injury is a great inconvenience to me. But I will make a full recovery. Four months from now, I can expect to be participating in all the activities I did before with little accommodation.  I credit the wonderful patients I have cared for as a nurse for the past 11 years for giving me clear insight into this.  New quadriplegics, stroke victims, pregnant mothers with cancer, babies with significant birth defects; the list is endless for people who have had to muster up more courage, strength, and perseverance than I could even fathom. These people have given me the gift of gratitude.

Grateful for the sun and this 1 year old cutie!

Overcommitted

A couple weeks before my injury, I shared a piece of writing with my sister. She liked it and asked if I had considered blogging. Well, since I'm blogging now, I'll post it here.  If I was having trouble figuring out how to simplify before, the universe has answered robustly since this injury why overcommitting is, simply put, bad for you.

I am writing this because I need to find sanity in motherhood. I need to free myself from the urge to compete with elite child-rearing. I need to stop the insanity that is driving me, my 6 year old daughter, and my husband into an emotional tailspin. I need to stop the fear that if I don’t over-schedule my children into several “enriching”, IQ-increasing, service-enhancing, athlete-making, music-virtuoso-making, activities that I will have failed them to provide the opportunity to excel in life. 
     This is my own failing. What is this personal regret despite my deep satisfaction with my career, unconditional love for my family, and general happiness with where I have ended up in my life? Why is there this this nagging belief that it is up to me to create and control what my children turn into? 
     The other day, I found out several of my friends are giving their daughters who are friends with my daughter Violin lessons. Another friend spoke of her daughter excelling in ski lessons. Bam. There it was. That feeling of failure. Even though I make the conscious decision NOT to bring the excruciating sound of a beginning violin player into my home, or spend money I don’t have on extra ski lessons, I must be failing my daughter by denying her the experience. I felt a frenzied failing come over me that since I did not enroll her in early music experiences, that perhaps I have already missed the boat with her! It’s craziness! I see that many of my daughter’s friends do possess a certain talent that lends them to excelling in many of these activities. But I need to be honest here. My Michelle is just a kid. My daughter is not a virtuoso, she struggles with reading, as much as she loves to move her body creatively, she does not seem to carry a “gifted” athletic ability nor does she possess an innate seriousness to perfect a talent. She won’t eat a vegetable. Michelle works hard in school.  She has to work hard. There is no hidden genius in her little 6 year old brain, and like her mom, she will have to work hard, likely very hard, to meet her own high expectations of herself.     
     I'll tell you what she is. Michelle is an unabashed extrovert who will make friends with anyone.  She is sensitive to the loner and has a stronger tendency to be inclusive rather than exclusive of others. She loves to paint, draw, engage in elaborate imaginative play with puppets and dolls. She has no desire to tease, only play with and love her baby sister.  She is strong-willed, emotionally sensitive, and extremely high-energy. These are the traits with which she was born. I had no say in the matter, and ultimately, I will have little say in what she ultimately finds fulfilling in her life.  
   So I say to myself, stop it!  Stop the guilt! There are limits to my financial and emotional commitment to ballet, tumbling, piano, basketball, theater class, art class, kung fu, girl scouts, soccer, swim lessons, ski lessons, trips to Disneyland, PTA,  and that is okay! My girls will be fine, and my husband and I will be fine without it. But I won’t be fine blazing down the road of over-committed insanity. And if mommy’s not fine, the trickle down effect leaves everyone sad and frustrated in my house.  
   So, here’s to knowing what I must do to feel “fine”. That by saying “no” to over-committing my child’s life, I am saying “yes” to a happier, healthier me. And if there is anything my kids could use more of to excel in life, it is a mom who can deal. My pledge to my kids is knowing my limits.  My commitment to them is to be present.

Phase I, Rest and Heal

I had my first post-op visit Tuesday which was mainly a wound-check.  The good news is, I am healing as expected.  The bad news is, I am healing as expected.  Though I have researched post-op rehab protocols for hamstring avulsion online, I asked to get Dr. Greis' protocol printed out to see if he had the same guidelines.  Yup.  Pretty much.  The only big difference is that Dr. Greis did not put me in a bulky brace for which I am undoubtedly grateful!
     Phase I, weeks 0-6. Rest and heal.  Ice incision.  Toe-touch weight bearing with crutches.  No flexing or stretching hamstring.  No formal PT until 8-10 weeks post-op.  As I write, I am only 10 days out.
     The irony with injuries like these is that they happen to relatively "active people" and I am no exception.  If something needs to be done, I do it.  But I can't right now and absolutely shouldn't be trying to!  It is a huge challenge overcoming that nag in my brain telling me "If you throw one crutch down the stairs, use one crutch on the left and hold onto the wall on the right, you could probably hobble downstairs and throw in a load of laundry!" That would be crazy!
     The urge to ignore "rest and heal" is also fueled by guilt over the burden this shift of responsibility has placed on my family. On Tuesday evening when my husband Barry got home from work, he looked at the dishes in the sink and remarked "Would it be too much to ask if you could just do the dishes?"  Both girls had been at grandma's all day and were not home yet.  The dishes were from breakfast and the sandwich I made for lunch.  Trying to remove food from the refrigerator to make a sandwich and then put it away again is really a simple task...that is, if you don't have both hands on crutches trying to keep the weight off a weak leg. I did manage to put the sandwich fixings away which was a real accomplishment.
     Standing at the sink for any length of time on one leg with armpits resting on crutches is again challenging and though I can manage hobbling items to the top rack of the dishwasher, the bottom rack requires a sophisticated balancing act.  To avoid active flexing or stretching my left hamstring, I must position the right leg in a deep 1 legged squat (left leg loosely dangling behind me) with the left hand on a crutch reaching down and out with my right hand to place a dish between the slats.  I know this because despite my precautions to "rest and heal", I have tried it.  Once. And it sucked.  I nearly fell over.  Never again.
     So to Barry's request for me to do the dishes, I replied "Yes, I'm sorry, but is too much to ask right now.  It is extremely hard for me."  A few minutes later he huffed out the house and announced that he was going on a drive.
     "Where?" I asked
     "I don't know."  He said.
And then I felt guilty. I should be trying harder, I thought. And remember that thing I said at the beginning of this post about how crazy it would be for me to try to hobble downstairs to throw in a load of laundry? I did that crazy thing.  And VERY fortunately, I did not fall, stub my toe, or tweak my hamstring. But every time I ignore my instructions to "rest and heal", I put myself at great risk for prolonging my recovery and perhaps permanently sabotaging the return to prior function.
     Those first few days post-op when I was in a lot of pain, my limitations were abundantly clear.  Barry and Michelle were incredible those days, commanding me to rest, setting the alarm every four hours at night so that I would keep my pain control steady. I am sure as my pain improved over the first week, I began to look less like a recovering post-op patient and more like a wife/mother just lying on the couch all day. Despite the looks of it on the outside, there is some remarkable healing going in there! A complex matrix of tissue is growing and gluing my tendon back to the bone.  Only I can protect that.
     So in the spirit of committing myself to "rest and heal", I have been more forthright about what I can and cannot do.  I have also enlisted Michelle's help with a lot of simple things. One night when she grumbled and stormed off because I asked her to help me put my pajama bottoms on, I put it to her like this: "I am asking your help because I am physically unable to do it myself.  I can't do this without you.  If I don't ask for help and hurt myself, it will be even longer before I can run and play with you."  I think she got it.  The next night when she retrieved something from a low cabinet for me I said "Thank you so much Michelle!  What would I do without your help?"  Very proud of her important role in project "fix mommy", she replied "Oh, you would probably die."

Let's Talk About Hamstring Avulsion

Hamstring strains are common sports injuries. 

Complete hamstring avulsions, where the tendon tears completely off the bone, are uncommon. 

Water skiing is the most common sport where this occurs because it sets up the mechanics just right.  Hamstring muscle contraction coupled with hip flexion with a straight knee and tremendous force & load placed suddenly to lurch the body forward is the recipe for disaster.   

Hamstring strains and avulsions are the most common yoga injuries.  Michelle and I were doing morning sun salutations about an hour before the injury, though I am sure that is incidental and not contributory to my injury.

Rehab protocols vary a little bit but all have one thing in common: do nothing but rest and heal with toe touch weight bearing with axillary crutches, pretty much just up to the bathroom for the first 6 weeks.  Gradually, I can increase weight bearing at that point.

It takes about 3 weeks for the incision to heal, but it takes 12 weeks really for the tendon to completely heal back to the bone.  After 6 or 7 weeks, the tendon is healed to the point where full weight bearing is allowed.

The process of strengthening the muscle again to a functional level will be a long and arduous task.  At around 9 months, it is considered excellent if my strength on the left side is 80% of the strength on the right. 

The literature supports repair and outcomes are much better when repaired early.  Amazingly, some people hobble along for months (14 months in one instance someone reported on a “runners world” internet forum) with a diagnosis of “hamstring strain” when in fact the muscle is avulsed.  Eventually, when PT fails to bring back function, an MRI is performed and the avulsion confirmed.  These are harder to repair as the muscle has retracted so far with so much scar tissue that harvesting tendon from other areas, usually the achilles tendon, is required.  There is more risk of sciatic nerve entrapment in delayed repair due to a pseudo sheath of scar tissue that may form, which sounds horrendous.  What is my takeaway? Glad I had the early repair!  Dr. Greis did excellent work putting it back together, now it’s my job to protect it.

Patience

After being farmed out for sleepovers 3 nights in a row surrounding my surgery, Michelle finally had an evening at home on March 23rd.  Hauled up on the couch, helping with homework was at least something I could do.  Michelle, who was strong willed and challenging before my injury, had notably reverted a lot of the limit-testing behaviors that were finally becoming manageable.  Nothing to set off a parenting lesson in patience than helping a kid with homework!

She opened her homework and got busy on a worksheet until she came to an activity about matching compound words.  There were 2 columns of words and she had to draw a line to match the compound words together.  Work to Shop, Ice to Cap, etc.  The first column had the word “Birth” which would correspond to “Day” in the second column.  She stopped and asked me “Mom, what does that word say?”  “Birth” is a word I knew she had read before and certainly had the tools to sound it out phonetically.

“Michelle, you wouldn’t be learning it yourself if I tell you the answer.  I think that is a word you know but if you don’t know the word, let’s try sounding it out.  I can help you that way.”

Immediately she launched into a dramatic display of wailing and tears.

“Mom! Just tell me the word so I can match it to the other word!  I don’t want you to tell me the answer!  Just tell me the word so I can get my homework over with!!!” 

I stood calm and firm as she escalated, her face red hot with anger and frustration.  After a couple minutes, I calmly said “I am unable to help you when you are this upset.  You need to find a way to calm yourself down before I can help you.  You can take some deep breaths here or calm down in your room.”  As expected, she continued to test with one more protest. 

“Since you can’t seem to calm down next to me, it’s time to calm down in your room.”  I said.  In the past, when she fights time outs, I have often had to physically escort her to her room.  I was stuck on the couch with a bum leg and no ability to physically enforce a time out.  There was no choice for me but to stay calm, hold firm, and remain patient.  With a couple of hyperventilated breaths, she started to calm down.  She wiped her tears and with two more breaths, she relaxed enough to ask with a sniff  “Now can you help me?”

“I am here to help you.  I won't read it for you, but if you do your best to sound it out, we’ll go from there.”

“B-eee-rrrr-th…be-earth is not a word I know!  It makes no sense!!”  I had a suspicion that she was feigning the difficulty of the word in hopes that I would just tell her the word, but I played along.

“It’s one of those words where the vowel doesn’t quite follow the rules.” I said.  How many times had I seen her drop the vowel that goes before the “R” in her spelling words?  If she was not faking this challenge, removing the vowel could be the answer.  So I said “What if you took away the ‘I’, how would you pronounce that word?”

“Birth.” She said hesitantly.

“There you go!  You got it.  Now which word would you match it to in the next column?”

“Day.  Birth-Day…Birthday!”  And she finished her homework in 3 minutes.

With this small, but notable parenting victory, I breathed a sigh of relief. I have no choice right now than to surrender to patience.  Exploding will do nothing to improve my situation or accomplish anything.  If we are going to get through the next 6 weeks as a family, I need to find that place in my being that is patient and calm with myself and those around me. 

Pre-op/ Post-op Photos

 Pre-op photos.  After hobbling around for 10 days, surgery day finally came March 21st.

Post-op glamour shot.

Pre-op and post-op couch selfies with Emily.  I will be spending a lot of time here.