Medical Procedures: Trigger Finger (Steroid Injection) Update

Update: I developed trigger finger in the same pinky finger approximately 10-11 weeks after elbow surgery (approximately 8 months after the first steroid injection), when the post-surgery therapeutic exercises began to put more strain on my finger.  I mentioned to my occupational therapist (OT) that my pinky finger was swollen and stiff, and that the joint near the top of my palm (the metacarpophalangeal joint) was very tender, sore, and warm to the touch.

My OT remembered that that was the same finger in which I had previously had trigger finger, and made an appointment for me with my orthopedic surgeon to get another steroid injection.  My ortho injected the joint approximately 12 weeks post-surgery, and said that if trigger finger comes back a third time, he would consider a surgical treatment.

Hopefully this will not be necessary, as my third New Year’s Resolution, which I did not share with you, is “No Surgeries in 2017!”

Ending 2016 with More Surgery

I am headed for surgery on December 14th (Wednesday).  This time for the elbow.  We’re not sure what’s wrong with it, exactly.  The symptoms are obvious, but the exact diagnosis is not. [At least, to me.  My surgeon might disagree, but then perhaps he should explain things better.]

The elbow hurts (all the time), and does not want to fully extend.  It would catch before the arm reached full extension and wouldn’t go any further.  Sometimes I could eventually get the arm to fully extend after multiple attempts.  The doctor gave me a steroid injection in the elbow joint, and now I can fully extend my arm (very slowly, and I have to wait for it to clunk into place).  None of the other symptoms were cured by the injection.

There is also a great deal of crunching and popping when I extend my arm.  The confusion lies in the fact that my elbow area snaps upon extension.  My surgeon thinks that I may have a snapping triceps, but that is supposed to happen upon flexion, although this journal article says it could happen in either direction.

Elbow 101: This website explains the basics of elbow anatomy and function.

My hand is also still swollen, with some numbness and lack of strength.  February will be three years since the original injury.  My hand has been swollen for nearly three years.  It is also discolored – compared to my healthy hand, it looks bluish-purple and darker.  The forearm does also.

The MRI resulted in a diagnosis of “tennis elbow” (lateral epicondylitis).

The EMG/CNS was inconclusive.  Based on my symptoms and physical examination, the surgeon is planning to do two or three procedures: 1) percutaneous tennis elbow release; 2) transposition of the ulnar nerve; and possibly 3) correct the snapping tendon if it is, in fact, snapping.

Here are explanations of the three procedures:

Explanation of percutaneous release from Cochrane.org:

Surgery on your elbow can include making a small cut in the arm and trimming damaged tissue from the tendon that joins the extensor carpi radialis brevis (ECRB) to the bone in the elbow (called an ECRB tenotomy), or releasing the tendon from the bone with a scalpel (called an ECRB release). The tenotomy may be done ‘percutaneously’, with a much smaller (1 cm) incision in the skin, or arthroscopically from within the joint.

Transposition of the ulnar nerve (Hughston Clinic Orthopaedics):

The procedure is performed under general anesthesia or with regional anesthetic. The ulnar nerve area is located and cleaned with an antiseptic solution.  A small incision is made around the medial epicondyle and the surgeon will locate the ulnar nerve.

This nerve is then moved out of its location under the medial epicondyle and placed in a more superficial area on the front the medial epicondyle. This new position may be directly under the skin or may be within a muscle. This process of moving the ulnar nerve out of the groove under the medial epicondyle into the front of the epicondyle is called anterior transposition.

Transposition of the ulnar nerve remedies ulnar nerve entrapment.  There is another good discussion of ulnar nerve entrapment here.

This video includes a discussion of ulnar nerve transposition, as well as actual footage of the surgical procedure.  I don’t think it’s very gory, but if you’re squeamish, you may want to only watch the first part of the video.

The next video shows some footage from a snapping triceps surgery.  I think it is a bit gorier than the previous video, so you may not want to watch it if you don’t like the sight of blood and the inside of human beings.  However, I think seeing the internal mechanisms in motion is fascinating.

This surgery will be my third on this arm: shoulder, elbow, and wrist will all have been repaired.  At this point, I’m wondering if I should have opted for a bionic arm, or perhaps a robot arm like Luke Skywalker’s.  Again, I reiterate the hazards of slip and fall injuries!

Bottom Line: I will be NMC (not mission capable) through the end of the year.  I’ll let you know in 2017 how the elbow surgery went, and what the surgeon found when he looked inside.  

Here’s hoping 2017 is a year of increasingly better health for everyone.

Guest Post: What It’s Like To Try Acupuncture And Cupping

This week we have a special treat – a guest post from Doug Nordman a.k.a Nords, from The Military Guide.  He’s sharing with us his experiences with medical tourism.  He bravely (or foolishly?) underwent acupuncture, cupping, and moxibustion in Thailand.

Remember the Olympic swimmers and their purple dots this past summer?  That’s what you look like after cupping.  To learn more about these procedures, and medical treatment abroad, read on:

Thanks for inviting me to write about these treatments, Crew Dog!

I’m a 56-year-old retired U.S. Navy submariner. As a “recovering nuke,” I’m skeptical about alternative medicine. Before I believe in a medical technique I want to read a pile of peer-reviewed reproducible studies of double-blind experiments with statistically significant evidence– and acupuncture just isn’t there yet. If acupuncture achieves anything at all, it might be simply a gigantic placebo effect.

However I’ve lived in Hawaii for over 25 years, where Occidental and Oriental cultures overlap with science and technology. I’ve learned to keep an open mind when I encounter treatments which defy the explanations of medical research.

My physical therapy for joint injuries has taught me that Western medical science doesn’t always have a precise explanation for why a technique works. I’ll enjoy the results whether or not I fully understand the mechanisms. If acupuncture is simply just a gigantic placebo effect then I can live with that.

I’m also willing to try new approaches because I’m a little frustrated with my aging body. I’m encountering new limits in my maximum heart rate and recovery time. When I was in my 40s, I used to burn through the Navy’s physical fitness test and then go work out. These days, after that type of exercise I’m tempted to burn through 800 mg of Ibuprofen and take a nap. When I do a couple hours of heavy yard work, I have to be careful to maintain good posture in my knees and my back – I don’t want to end up in another round of physical therapy.

My body’s latest betrayal is my left shoulder (deltoid) muscle. Over 10 months ago I felt a small “pop” during a push-up set, and the next day I couldn’t raise my left arm above my shoulder. It slowly healed over the next six months but I kept re-injuring it. When we traveled to Bangkok, I still didn’t have full range of motion and I couldn’t put my left hand up behind my back. I was worried that I’d injured my rotator cuff and I felt like an idiot.

Thailand’s cost of living is incredibly cheap, and Bangkok’s major hospitals are a magnet for medical tourism. My spouse and I had heard about the Traditional Chinese Medicine Clinic of Hua Chiew Hospital, and we were happy to spend a few dollars to experiment on my deltoids.

Hua Chiew is definitely not practicing traditional Western medicine: the hospital takes walk-in patients. The lobby was a beehive of activity with a large waiting area by the cashier’s window. The clerk at the front desk explained (in English) that a typical acupuncture treatment would be less than 600 baht. (At 35 baht per dollar, that’s just over $17– and nobody asked us about insurance.) He entered our names into their computer system. We stopped by the next table for a quick health check of height, weight, temperature, and blood pressure before being sent up to room 504.

The fifth floor was quieter, with a few patients in the hallway and a family in the waiting area. When I walked into room 501’s open ward, it smelled like old cigarette smoke– and marijuana. (Hey, I have a training certificate from a 1980s Navy drug education class with a “test burn”.) I was greeted by an acupuncturist and an assistant who asked me where it hurt. A few minutes later the assistant was guiding me to an exam table.

“This won’t hurt a bit.”

I was asked to remove my t-shirt (which the assistant quickly hung on a hanger) and arranged on my right side with my left arm extended across a pile of pillows. While the assistant set up the privacy curtains, the acupuncturist came up behind me with a tray of needles and other tools. (Selfies were discouraged during this procedure, but I took photos afterward.) I turned my head to watch, but she politely asked me to relax on my pillow so that she could put needles into my neck.

She swabbed my skin with antiseptic and opened a package. Each needle was about three inches long with tiny coils at their gripping end, and they seemed very delicate. They must have been extremely fine and sharp because I could barely feel them going in– just a cool sliding sensation as she inserted them about an inch. My skin didn’t even dimple as she gently and quickly placed them from neck to elbow. A minute later I had a dozen needles sticking out, and she suggested that I should stay still. She even put two needles in the side of my left calf, explaining that there’s a nerve connection to the shoulder.

Then the assistant brought out a power supply and an electronics box. I later learned that this was an electrical muscle stimulation system, and the acupuncture needles make it easy to deliver the electrons directly to the injured area. She wrapped electrical wires around two of the needle coils and flipped a switch. My deltoid promptly started twitching gently, about once per second. After she checked the electronics display, she brought out an IR heat lamp and positioned that over my left shoulder. She said she’d check on me in 30 minutes and gave me a call button to push if I had any problems.

I stayed as still as I could despite being a human pincushion with my shoulder twitching like a frog leg in Dr. Frankenstein’s high-school biology class, while the lamp heated my shoulder (and the metal needles). It must have looked extremely uncomfortable.

A few minutes later I dozed off.

Judging from the assistant’s polite smile when she woke me up, this must happen a lot.

Well, technically my deltoid kept twitching while the rest of me had a very nice nap. When she turned off the machine, my entire shoulder relaxed.

She gently extracted all the needles that they’d inserted. (I kept count just to make sure.) I could barely feel the sliding sensation as they were removed, but there was no pain.

Then she picked up a tray of heavy glass cups, and I realized that I’d signed up for a bonus cupping session after the acupuncture.

Cupping

The assistant laid out a dozen cups of various sizes. They were each about 2”-3” tall and 1”-2” in diameter, made out of heavy glass. She rubbed a light coat of oil over my shoulder and back (to get a better seal).

Next she used her forceps to pick up a cotton ball and dip it in a liquid that looked like alcohol. Then she picked up a cigarette lighter, set the cotton ball on fire, and walked over to my shoulder.

An open flame. In a hospital. In a ward where there were probably oxygen canisters near more flammable liquids and oily skin. With a submariner who used to teach firefighting tactics at a training command.

I was not happy.

It turned out that the flaming cotton ball heated up the cups (and the air inside them). The acupuncturist briefly warmed each cup over the flame and then gently slapped them down on the skin that had held needles. As the air in the cups cooled and contracted, the suction drew the skin up into the cups and held them in place. A few cups were pried off and re-applied for a better seal.

As the skin on my shoulder and back was pulled up into the cups, I could feel a warm tingling as more blood was pulled up into my muscles. Several minutes later the assistant released all of the cups (with a wood tongue depressor) and wiped the oil off my skin.

The acupuncturist asked me to sit up and move my arm around. It was still warm from the treatment, and the deltoid felt particularly loose. I was happy to discover that I had much more flexibility and no pain. Wonderful!

When I checked my shoulder and back in a mirror, it looked like I’d lost a grappling match with an octopus. (This picture was taken an hour later.) The acupuncturist reassured me that the bruising would fade in a few days. In my case, the marks took nearly three weeks to disappear.

after-cupping

What happened to make my arm feel so much better?

According to traditional Chinese medicine, my body’s qi had been manipulated by the needles and the cups to bring more healing energy to my damaged deltoid.

Western medicine claims that my muscles had been stimulated by electricity, bringing more blood and lymph fluid to help repair the microtears. The heat and the cupping had brought even more blood into the muscle and skin, causing more bruising yet supplying more healing fluids. My body would focus greater effort on repairing damage in that area, which would also accelerate repairs to the deltoid muscle.

And, of course, the hour’s performance had kicked my placebo effect (and endorphins) into overdrive. No wonder I felt so good.

I’ll leave that debate to the doctors. Whatever happened during that hour, the pain relief (and the greater range of motion) was worth every penny of $17.

When I paid the bill at the cashier’s desk in the lobby, it was more like $16.75. My smartphone’s Google Translate software wasn’t much help here, but if you read Chinese or Thai then please feel free to share the details.

hua-chiew-invoice-and-patient-card

Followup

As I left the fifth floor, I was handed a small appointment card and admonished to return in three days for more treatment. My spouse and I got busy with other activities (there’s a lot to see & do in Bangkok) and we returned in nine days. When we walked in (still no appointment necessary!), the front desk checked our cards and started the routine again.

When I walked back into room 501 it still smelled like marijuana. I confidently returned to my treatment table, hung up my t-shirt, and laid down for an encore of my last visit. The setup went the same and I was soon bristling with acupuncture needles, but they didn’t haul out the electrical box.

This time the assistant unwrapped a couple small paper packages the size of a section of a Tootsie Roll. Later I learned that they held a dried Chinese herb called moxa, and I was about to experience moxibustion.

She poked two of the herb bundles on top of two of the acupuncture needles… and then lit them with her cigarette lighter. I immediately realized why the ward smelled like marijuana smoke, only it was burning moxa.

moxibustion

As she pulled the privacy curtains closed, she asked me to push the call button if my deltoid got too warm. I soon realized that moxa burns just like tobacco and it was heating up the acupuncture needles. Those, in turn, conducted the heat straight down to my deltoid muscle. I wasn’t exactly getting first-degree burns, but it was uncomfortably warm under my skin. I gritted my teeth and vowed to wait out the moxa.

It must have worked because I dozed off again. The moxa stopped smoldering in 20 minutes and the assistant followed up with the heat lamp for another 10 minutes. They removed the acupuncture needles and commented that my cupping bruises were sure taking a long time to heal, but that was the end of the session!

This time I only paid 525 baht ($15).

Long-term results

We’ve been back on Oahu for a couple of weeks, and my left deltoid is completely healed. It could be qi or it could be targeted electricity and heat therapy, but the results are undeniable. I’m back to pull-ups and push-ups and reaching up between my shoulder blades. I’m also doing more stretching and taking it a little easier with the multiple sets, but now I know what a local acupuncture clinic (or the placebo effect) can do for me.

Either way, I’m happy.

Crew Dog: Doug usually writes about Financial Independence and Early Retirement, and how he did it on a military salary, at the-military-guide.com.  He’s also the author of The Military Guide To Financial Independence And Retirement.

Have you been a medical tourist, or tried alternative medical procedures? What were your experiences like?  Comment below.

Medical Procedures: What It’s Like to Have an MRI (with contrast)

The first MRI (magnetic resonance imaging) I ever had was a cerebral MRI in a foreign country.  I hadn’t been in the country very long, and didn’t speak much of the language.  I also didn’t know much about the procedure.  All I knew is these people with whom I could barely communicate were going to look inside my head.

The MRI was state-of-the-art – a small, donut-shaped open MRI machine:

The nurse, however, was another story.  She had no bedside manner, or rather, her bedside manner was very stern and unyielding.

My referring physician had requested an MRI with contrast, which means “dye” was injected into my veins through an IV.  The dye helps the radiologist see certain areas more clearly.

After the nurse inserted the IV and began administering the contrast, I felt a burning sensation in the arm in which she had placed the IV.  I was concerned that I might be having an allergic reaction to the dye, because I had read that was possible.  I asked the nurse if the burning sensation was normal (I rather doubted that it was).  Once she understood my question (it took several attempts, due to the language barrier), her response was “That is not possible.”

It has been over 15 years since this experience, and I still remember it vividly.  I am in a hospital gown in a cold room in a foreign country, and I am having what seems to me to be an abnormal response to this medical procedure, and all the nurse will say is “That is not possible.”  I asked again.  Again she responded “That is not possible.”  I started to get excited:  “It must be possible, because it is currently happening TO ME!”  

I could not believe that I might die of a routine medical procedure because the nurse refused to acknowledge my reality.  I had driven myself to the procedure, and I wondered how long it would take before anyone figured out what had happened to me.

I continued to express to the nurse that I thought I might have a problem and I was not satisfied with her answer.  Finally she snapped, “The only way that would be possible is if I had missed the vein, and I did not miss the vein!”  Case closed, as far as she was concerned.

I finally decided I would either die or I wouldn’t, but I didn’t seem to have any control over the outcome.  So I made my peace with it, and continued on with the procedure.

I was given ear plugs, because the machine can be loud.  After I inserted the ear plugs, I laid back on the patient table, someone tucked a foam wedge under my knees for comfort and placed a thin blanket over me for warmth, fastened a basket-type device around my head (see image at beginning of post), and I was eased into the MRI “donut.”

I don’t remember much from that first MRI, except that it didn’t seem that bad, and it was over fairly quickly.

I didn’t die from an allergic reaction to the dye, obviously.  But I was correct that the burning sensation was not normal.  Miss “That is not possible” was wrong.  As it turned out, she had not missed the vein – she had gone completely through it.  I figured this out the next day, when I woke up with a huge black & green bruise on the inside of my elbow, surrounding the IV site.

Presumably enough dye reached my brain for the radiologist to get adequate images, since my doctor was given results, and I didn’t have to re-do the procedure.

Since then, I have had several more MRIs – a few more looking at my brain, and ones looking at my hand/wrist, elbow, and shoulder.

Here’s what I’ve learned about MRIs:

There is a wide variety of condition of equipment and pleasantness of experience.  The “donut” open MRI was the nicest equipment I have experienced.  Many facilities do not have them, or only use them for certain patients (obese, claustrophobic, etc.).

The nicest facilities now have headsets for the patients to wear during the procedure, and will play your choice of local radio stations or even subscription radio (Sirius XM, etc.).  Time passes more quickly when you are listening to your favorite jam.

The worst experience I have had was at a military facility.  The MRI was in a trailer in the parking lot – it was on loan from the VA.  Yes, I had to walk across the parking lot in my hospital gown to get to the trailer.  The machine was small, so the table that I laid on was narrow, and the machine opening was tight too.  That’s the closest I’ve come to feeling claustrophobic in an MRI machine.  The machine was old and VERY LOUD.  There was no music.  No headsets.  Only ear plugs and disappointment.  And a lot of vibration.

The MRI machine cycles through various “runs.”  In most facilities, the technician will talk you through the procedure while it is happening, informing you when the next run is starting, and how long it will last.

You have two-way communication with the technician at all times.  You also have a “panic button” in your hand that you can press at any time if you want to disrupt the procedure and get immediate assistance.

The machine makes noises at different frequencies and volumes during the different runs.  Some runs are quieter and less noticeable.  Other runs are loud, and you can feel the vibration in your body.  Some feel like thuds.  It doesn’t hurt, but some runs are louder and less pleasant than others.

The contrast agent (“dye”) does not normally burn.  You usually can’t feel it at all.  Sometimes it might feel a little cold initially.  Sometimes you might get an odd taste in your mouth (kind-of metallic).  Side effects are rare, but can happen.

In my opinion, cerebral MRIs are the easiest, because all you have to do is lie on your back and not fall asleep.  (Some people might not agree, as a cerebral MRI guarantees that your head must be inside the machine, whereas if they are imaging your arm or leg your head might not have to be inside the MRI machine.

NOTE: It is very important that you not move while the MRI is being conducted.  Moving can blur the images, and the procedure, or portions of the procedure would then need to be repeated to get clear, accurate images.  This is also the reason that the body part to be imaged is typically placed in a surrounding device to help stabilize it.  This is also the reason you cannot fall asleep, as you might move in your sleep.

For me, the MRI of my shoulder was no big deal.  The wrist and elbow were more memorable.

In order to get the images they needed of my elbow and wrist, I was required to lie in less comfortable positions.  Although the techs propped me on various pillows and foam wedges to hold my body in the position they needed, my muscles started to fatigue during both of these MRIs.  I was trying to prevent my wrist and arm from shaking, but the muscles became so fatigued that I was unable to prevent the muscle trembles by the end of the procedures.

In particular, for the elbow MRI, I was positioned with the injured arm straight out above my head, in front of me, like Superman’s flying position.  For this procedure, I laid on my belly, rather than my back.  Despite my best efforts, I could not keep my arm from shaking by the end of that procedure, although the tech said the images came out ok.

The procedure typically takes about 45 minutes.  Afterward, the tech will typically check the images to see if any runs need to be redone.

Bottom line:  MRIs are loud, but the procedure isn’t a bad experience.  They are not painful.  I have never felt claustrophobic, although I came close in the tiny, old military MRI machine.  If you are claustrophobic, make sure you are referred to a facility that has an open MRI machine and has experience with claustrophobic patients.  Also, you can get a mild sedative if you need one to help you get through the procedure.

[If you think you will need a sedative, make sure you bring a wingman/battle buddy to drive you home.]

It is very rare to have an allergic reaction to the contrast agent.  The pre-procedure paperwork will explain the type of agent used and possible side effects.  If you have any concerns, discuss them with your referring physician or with the MRI facility staff.

You can resume your regular activities upon completion of the MRI – it’s not a procedure that requires recovery time afterward.

Don’t worry that you will get a nurse like I had for my first MRI – “That is not possible.” 🙂  Every tech I have had in the US has been very helpful, very knowledgeable, and most of them have been very reassuring.  They know the procedure can be a bit intimidating for many people, and they typically go out of their way to make it as pleasant as possible for you.

Not Mission Capable: Why I Have No Post This Week

I wish I could tell you there is no post this week because I have been hiking in the Rockies and enjoying the flare of golden aspens before winter comes.  Or because I have been scuba diving in the South Pacific.  Or because I have been traveling the world sampling exotic cuisines and learning about diverse cultures.

However, the reality is I am just sick and tired this week and feel too crappy to write a post.

The reality is that I don’t have the energy to leave the house, and I’m currently on a very restrictive diet that my allergist has assigned to help us determine my food allergies.

A friend, and fellow vet, sent me this video clip illustrating how crappy 2016 has been and it got me thinking…

So far, this year, I have seen the following medical specialists:

  • several PCMs
  • an orthopedic surgeon
  • several anesthesiologists & a CNA
  • an occupational therapist
  • a physical therapist
  • a neurologist
  • an allergist
  • a dermatologist
  • several radiologists
  • an optometrist
  • the NP who administers Botox shots
  • a PA in the VA wrist clinic
  • and various medical assistants (LPNs etc.)

I have had numerous diagnostic medical procedures:

  • an EMG/CNS
  • 2 MRI/arthrograms (elbow & wrist)
  • 1 cerebral MRI
  • numerous x-rays (elbow & wrist)
  • a cardiac ultrasound (echocardiogram)
  • 2 allergy skin tests (skin prick and injection)
  • numerous blood draws
  • a 24-hour urine collection analysis

And I have had the following treatments:

Once again, I am tired to the bone.  It has been a long year, filled with poor health and weekly medical appointments, new medications with complicated regimens, numerous corrections of Tricare billing errors, and several rejected requests for therapeutic medical devices.  This is also the year I discovered that I have multiple allergies (I didn’t know I had any),  and these allergies require that I make significant diet and lifestyle changes.

On the bright side, I *do* finally feel that I am getting better quality of care.  I am slowly building a team of competent medical specialists to diagnose and treat my health issues.  I am learning how to get rid of the incompetent ones.  Spousal Unit and I are learning how to navigate the treacherous Tricare healthcare system more effectively.  I am getting diagnoses that explain my symptoms, and I am getting treatment to reduce my symptoms and hopefully address the underlying causes.

I tell myself to frame the situation positively.  Instead of telling myself I am broken, I tell myself I am healing.  Both are true.  But I choose to focus on a positive future, rather than a negative one.  I believe this will help me get better.

2016 has been a crappy year, full of debilitating health problems.

But I am healing.

Medical Procedures: What It’s Like to Have a Steroid Injection

Approximately six weeks after hand and wrist surgery, I developed “trigger finger” in the pinky finger of my surgery hand.  After the splints were removed and I started using my fingers again, I noticed my pinky finger “clunked” when I curled it, and it “clunked” upon full extension too.

Trigger finger (medical name: stenosing tenosynovitis) happens when inflammation occurs in the sheath surrounding a finger’s tendon, narrowing the space through which the tendon moves and impinging its movement.

After two weeks of occupational therapy and treatment for the swelling in my hand and wrist (eight weeks post-surgery), the clunking in my finger had gotten worse.  So the therapist informed the surgeon, and he decided to treat the trigger finger with a steroid injection.  This was not fun.

My orthopedic surgeon cleaned the injection site thoroughly with an alcohol wipe and then he sprayed an icy numbing spray on the area.  I felt the needle go in.  But the discomfort started as he began to inject the steroid solution.  It felt very similar to an arthrogram injection – there is increasing discomfort as the space begins to fill.  In the case of an arthrogram contrasting solution injection, your joint fills with fluid.  In the case of this steroid injection, my tendon sheath filled with fluid.

As the discomfort increased, I once again found breathing exercises very helpful for controlling the discomfort (for more on breathing exercises, see this previous post).  Additionally, my surgeon was applying pressure to the tip of my finger which helped focus my attention away from the discomfort at the injection site near the base of my finger.

About halfway through the process of filling the tendon sheath with the steroid solution there was a noticeable “clunk”.  Both the surgeon and I could feel it.  He asked me if I felt it, then grinned and said “That’s a good sign.  We’re getting the solution where we want it.”

Toward the end of the injection there was a second “clunk”.  My surgeon was very pleased.  As he continued the injection, he asked if it felt to me like the area was getting too full.  When I said no, he finished emptying the syringe, removed the needle, and placed a band-aid over the injection site.

My surgeon warned me that it would probably hurt the next day – possibly a great deal.  He mentioned that I might find myself saying very uncomplimentary things about him.

[As it turned out, I had no pain or discomfort the next day.  I don’t know if it made a difference that I was wearing a compression glove, a compression stocking, and a brace on that hand.]

My occupational therapist cautioned me not to do my therapeutic exercises for the remainder of the day, as that could cause the steroid solution to work its way out of the target area.  She also told me not to apply heat to the area for the remainder of the day, but said that I could ice it as desired.

For several days following the injection, I am supposed to modify my therapeutic exercises to exclude my pinky finger as much as possible.  My surgeon said it can take up to five days to achieve the full effect.  The steroid injection should reduce the inflammation and allow the affected tendon to move freely again.

I did notice the temporary side effect of facial flushing, but it didn’t last very long (maybe 20-30 minutes).  My finger was also swollen and numb after the injection.  I’m not sure how long that lasted, because I went home immediately and applied a cold pack to the area.  By the time I removed the cold pack, the numbness was gone and most of the swelling was too.

In theory, the steroid injection will relieve the inflammation and cure the trigger finger.  Meanwhile, the rest of the post-surgery swelling of the hand and wrist should gradually abate and hopefully the trigger finger condition will not return.  In other words, hopefully this one treatment will fix it and I shouldn’t need another steroid injection.

Bottom Line: It was pretty uncomfortable during the injection, but I didn’t experience any after-effects.  If this cures my trigger finger in one treatment, it will have been totally worth the temporary discomfort.  As far as medical procedures go, for me, this one was no big deal.

Medical Procedures: What It’s Like to Undergo a Sleep Study (Polysomnogram)

“So, why are you here?,” the technician asked me.  “My spouse says my snoring is pretty bad,” I responded sheepishly.  The technician laughed. “That’s the number one reason we see people here.  If it weren’t for spouses, a lot of people wouldn’t realize they have a problem.”

Well, I didn’t think I *had* a problem, but Spousal Unit did not agree.  A discussion with my PCM led to a consultation with a sleep doctor, who decided a sleep study was in order.

I arrived for my sleep study one evening after dinner.  I was told to bring my pajamas, toiletries, any medications I normally took, anything that was part of my normal night routine, and clothes for the next day.  I was also told that I could bring my own pillow if I wanted.

In preparation for the sleep study, I was told not to have any caffeine or alcohol after noon on the day of the study, since caffeine and alcohol can disrupt sleep patterns.

[For more information on preparing for a sleep study, see this article from the UCLA Sleep Disorders Center.]

A technician showed me to my room, which was something between a hospital room and a hotel room.  It had a linoleum floor, industrial fluorescent overhead lighting, a double bed, nightstand with lamp, dresser, television, and private bathroom.

The technician explained the sleep study procedures and asked if I had any questions.  Then he told me to change into my pajamas and do my evening routine to get ready for bed.  He told me to open my bedroom door when I was done, and he’d be back to get me hooked up to the monitoring equipment.

When he returned, the technician placed electrodes on my face (including the corners of my eyes) and scalp.  The electrodes have sticky backs, and attach directly to your skin/scalp.  The electrodes are connected by a tangle of individual wires to a relay that sends electrical signals from your brain and muscles to a computer.  These electrodes monitor various aspects of your sleep.

Next, the technician fastened bands around my chest and abdomen to measure breathing.  Then he attached a clip to my finger to measure the level of oxygen in my blood and monitor my heart rate.  (You’ve probably seen this clip before at your doctor’s office or in a hospital room – I call it the E.T. finger because it glows at the tip.)

None of the monitoring equipment was painful or particularly uncomfortable – it was just incredibly awkward.

Two sleep study warriors wired up for their studies:

After the technician got me all wired up, he gave me a call button in case I needed to summon him and told me to get comfortable, watch a little TV or read, and try to go to sleep around my normal time.

If I needed to go to the bathroom, I was supposed to summon him, and he would come and unplug some wires so I could get to the bathroom.  Everything would remain attached to me (electrodes etc.), so it would be a fairly simple process to disconnect and reconnect a few connections.

After he left, I watched TV for a while, then turned off the TV and the lamp and tried to sleep.

I know veterans are supposed to be able to sleep anywhere, but I have never been able to sleep lying flat on my back.  I can sleep sitting straight up, I can sleep on top of a cargo pallet in the back of a C-130, and I even fell asleep standing up once, but I cannot sleep lying on my back.  This was a bit of a problem, since I had all of the monitoring equipment hooked up to me, which made it difficult to sleep on my side, and impossible to sleep on my stomach.

To make matters worse, I was hyper-alert because I was sleeping in a new place, with lots of unusual noises, and I knew I was being monitored via a video camera.  Try sleeping while someone is watching you.

At one point I heard some commotion in the hallway – I found out later that one of the other patients had been sleepwalking.  How they managed that with all the equipment hooked up to them, I do not know.

Several times during the night the technician came over the intercom and encouraged me to try to sleep.  I must have fallen asleep eventually, because he woke me up in the morning and said it was time to go.  I asked if I had had a long enough sleep-cycle for him to get sufficient data, and he said just barely.

The technician disconnected and detached all of the monitoring equipment and left the room.  I took a shower, got dressed, packed up my gear, and was shown out of the sleep center.

Once all of my data was processed, I had a follow-up appointment with the sleep doctor.  The sleep doctor informed me that I have sleep apnea, and that I needed to remedy that by sleeping with a continuous positive airway pressure (CPAP) machine.

This diagnosis meant that I had to return for a second night at the sleep center, to determine what CPAP machine air pressure settings would alleviate my sleep apnea.  Oh joy.

The second visit was pretty much like the first.  Because I had had trouble sleeping the first time, they gave me a room down a dead-end hallway, which had less traffic and was darker and quieter than my first room on the main hallway.

This time, in addition to all of the monitoring equipment, I also had to wear a CPAP machine mask.  The mask allows the machine to provide pressurized air through your passageways in order to keep your airway open and provide enough oxygen to your lungs while you sleep.

I had tried on several types and sizes of masks during my follow-up appointment with the sleep doctor, and we had settled on a specific type and size.  The technician had this type and size mask ready for me to try the second night, as well as some others if the first mask didn’t work well for me during the second sleep study.

The technician adjusted the mask straps and fitted it for me, then showed me how the CPAP worked.  Like many of the newer CPAP machines, the one I used that night had a “ramp” feature that lets the air come through the mask at a lower pressure, and then gradually increases the air pressure to your prescribed setting.

This gradual increase usually takes about 15 minutes, and is supposed to give you time to fall asleep as you gradually adjust to the pressure.  If you have not fallen asleep by the time the machine reaches full pressure, and it is uncomfortable for you, you can press the ramp button, which will drop the pressure and start the gradual increase again.

The purpose of this second night was to determine at what air pressure my sleep apnea symptoms would be alleviated.  This meant that the technician would try various settings, and then I was supposed to fall asleep and the technician would see if the setting worked.

I got even less sleep the second night than I had the first night.  In addition to the awkwardness of all of the monitoring equipment, I now also had a mask strapped to my face with straps that went across my cheeks and over the top of my head.  The mask forced air through my nostrils, and the air flowing through the hose made noise.  It was nearly impossible for me to sleep with all of this stimuli.

A few times I dozed off and then the machine reached full pressure, which startled me awake.  By the end of the night, the technician was frustrated (although he wasn’t rude about it).  He said he barely had enough data to be able to calibrate the machine, but called it good enough.  None of us wanted to try that again on a third night.

As before, the technician removed all the equipment, and I got dressed and left.  I was glad I didn’t have to work the day after the second sleep study, because I was wiped out.

Results: As a result of my sleep study, I was diagnosed with sleep apnea and prescribed a CPAP machine for home use.  The mask was fitted for my head, the machine’s air pressure settings were adjusted for my required level, and I was told to sleep with this machine every night for the rest of my life.

Do you sleep with a CPAP machine?  Have you found a way to make peace with it?  Any hacks to make it less awkward?  Please share with us below.

Medical Procedures: What It’s Like to Have Medical Botox Injections

In my experience, this was one procedure it was best not to think too much about ahead of time: having a 30 gauge needle stuck repeatedly into your head in order to inject multiple doses of neurotoxin.

Most people think of Botox as a cosmetic procedure that reduces wrinkles.  But Botox is used medically to treat several conditions, such as repetitive neck spasms (cervical dystonia) and chronic migraines.  Botox injections work by weakening or paralyzing targeted muscles or by blocking specific nerves.  Although scientists still don’t know exactly how Botox works for chronic migraines, according to The Migraine Trust:

A recent US study by Rami Burstein et al using animal models suggested that botulinum toxin inhibits pain in chronic migraine by reducing the expression of certain pain pathways involving nerve cells in the trigeminovascular system…

Unlike many of the other conditions in which it is used, it is not thought to work by relaxing overactive muscles.

In my case, the Botox injections were prescribed to treat chronic migraines (more than 15 headache days per month) which had not responded to any prescribed medications.

Since I was a bit apprehensive, I did research prior to the procedure, and watched several YouTube videos about the procedure, which made me think a little too much about needles going into my scalp and face.

I couldn’t find a good video that demonstrated the procedure for patients – most of the videos are either commercials for the product, technical demonstrations for healthcare professionals, or patients talking about their experiences.  This video is a technical video produced for healthcare professionals, but it gives you a good idea of the procedure:

My treatment began with me lying on my back on the examination table, and receiving injections in my forehead, temples, and scalp.  After that portion of the treatment was done, I was asked to sit in a chair and put my head on a pillow on the exam table.  (My arms were crossed, and my head was resting on them, like in the elementary school game of  Thumbs up, 7-up.)

While I was sitting in the chair, injections were administered to my scalp and trapezius muscles.

Unlike in the video, my provider did not use ice packs to numb the injection sites.  Some of the injections stung a bit as the Botox went in, but they didn’t hurt as much as some of the patients on YouTube had said they would.  Also, some of the injections were more painful than others.  For me, the injections in my left temple and behind my left ear were the most painful.  That’s the side on which I get most of my migraines, so the nurse practitioner figured those nerves were hyper-sensitive.

One of the injection sites on my face bled onto the pillow a little bit when I was getting the injections to the back of my scalp, and the injection sites were a little bit red and swollen for about an hour after the injections, so I kind-of looked like I had hives (or bee stings?).

But the staff was very careful to follow sanitary procedures, including cleaning the sites with antiseptic and treating the site that bled with clean gauze.

Also, I had no negative reactions to the Botox, so it turned out to not really be a big deal at all, and my apprehension was for nothing.

The entire procedure took about 20 minutes, and the effects should last for about 3 months.  Botox injections are not a cure for migraines – they are a treatment, meaning that they don’t fix what’s wrong; they only treat the symptoms.  If the injections work to lessen my migraines, I will have to continue getting injections once every three months for the rest of my life.

After injections, results are typically felt within 3-4 days.  However, studies show that most people do not experience the full effect until 6 months of treatment, which would be after the second or third series of injections.

If individuals have not responded by two to three treatment sessions it is generally considered that the individual is a non-responder.

(In other words, like other treatments, Botox for chronic migraines doesn’t work for everyone.)

Potential Side Effects of Botox treatment: Pain, swelling, or bruising at the injection sites.  If the person administering the shots isn’t careful to avoid certain muscles, you could have a drooping eyelid – or be unable to hold your head up – until the Botox wears off.

NOTE: Even though the injection sites might feel a little weird (slightly swollen, numb), it is very important not to rub the injection sites, as this can cause the toxin to spread outside of the designated areas.

[For more information on Botox, see this 2009 New York Times article.  Note that Botox has been approved for chronic migraine treatment subsequent to this article.]

Have you had medical Botox injections?  What was your experience with them?  Please comment below.

Update: One week after Botox

Still having debilitating migraines, but I’ve started to feel a little bit better.  Still very light-sensitive.  Less motion in my forehead muscles – can still make a Spock eyebrow, but the eyebrow doesn’t go as high.  Slight furrow when I frown.  Shoulder tension noticeably reduced; able to activate shoulder muscles that had been constantly tense.  Puffy eyes.

Update: Two weeks after Botox

Still having debilitating migraines, but also a few productive days.  Still very light-sensitive.  Very little motion in forehead muscles – can’t make a Spock eyebrow anymore.  Almost no motion when I frown or try to look surprised.  Shoulder tension noticeably reduced, with better range of motion of shoulder muscles.  Eyes still very puffy – but not drooping.

Update: ~ Nine weeks after Botox

My provider had informed me that, for some people, the effects do not last the full 12 weeks.  For these people, he said, Botox wears off a week or two before the next treatment.  For me, the Botox wore off 2 1/2 to 3 weeks before my next treatment.  My migraines returned with a vengeance, like they were making up for lost time.  While I appreciated the reduction in migraine symptoms and migraine frequency for nine weeks, having them return and knowing there’s nothing I can do about it for nearly three weeks until the next scheduled treatment sucks.

[The FDA approved Botox for migraine treatment at a 12 week interval, so even if it doesn’t last the full duration, the provider cannot shorten the interval.]

Medical Procedures: What It’s Like to Have an Echocardiogram (with “Bubble Study”)

Some things are scary.  Like when your healthcare provider refers you for a procedure that involves bubbles injected into your veins and flowing through your heart.

I told my PCM the thought of it kind of freaked me out.  She said it was perfectly safe.  Just a routine procedure.  No big deal.

So I went home and researched the procedure.  I found an article from a reliable source that explained the procedure simply and thoroughly and assured patients that “The bubble study is extremely safe.”

And the rational part of my mind believed them.  But some other, irrational, part of my mind kept thinking of all the TV shows in which the villain kills someone by injecting an air bubble into their IV.  (Medical personnel hate Hollywood for this, by the way.)

I’m not the type to worry about things and get anxious, so I didn’t spend the days between the doctor’s visit and the bubble study obsessing about it.  But I didn’t sleep very well the night before, and I was pretty anxious on the ride to the hospital.  I did breathing exercises to try to relax, and, of course, cracked dark jokes about things Spousal Unit needed to know in case I didn’t survive.  (Not sure Spousal Unit appreciated that.)

What ultimately helped me relax was talking to the tech who performed the bubble injection part of the procedure.  She told me three reasons not to worry:

1) The saline solution is being injected into a vein, not an artery, and therefore there is less risk;

2) The bubbles are very small, and could not block a vein;

3) The bubbles go through your heart to your lungs, and your lungs handle them just like they handle every other gaseous fluid (bubble).  That’s what lungs are made for.

In other words, your body knows what to do with the bubbles, and it’s no big deal.

That’s when the rational part of my mind won, the irrational part of my mind stopped freaking out, and I relaxed.  More breathing exercises helped me release the tension as well.

So, what exactly *is* an echocardiogram?  It’s basically just an ultrasound of your heart.

Most of us have seen an obstetric ultrasound on TV, where the technician looks at a pregnant woman’s fetus in the womb.  The technique for an echocardiogram is pretty much the same – sound waves are used to get images of your heart.

But unlike an obstetric ultrasound, where the woman lies on her back, for a cardiac ultrasound you lie on your left side.  This helps the technician get a better image of your heart.

My technician explained to me that the ultrasound cannot get images through your bones, so they have to manipulate the wand around all the bones in your chest, like your sternum (breastbone) and ribs.  The ultrasound also cannot get images through air, so they have to avoid your lungs as well.

Since your heart is already off-set to the left of your chest, lying on your left side allows the heart to fall a bit further left, away from your sternum.

So, you take off your shirt and put on a hospital gown (open to the front), and the technician attaches some electrodes to your chest with sticky patches so they can monitor the electrical currents of your heart.  (For a good overview of the entire procedure, see this Mayo Clinic article.)  Then you lie down on your left side, and move your left arm up near your head.

The technician lubes up the wand (a.k.a. probe or transducer) and moves it around on your skin until they can get clear images of your heart.  (The gel helps improve the conduction of the sound waves, and makes sure there’s no air between the wand and your skin.)

Since they are dodging your bones and your lungs, the wand can wind up feeling like it’s trying to dig under your ribs as the technician attempts to get the clearest image, which can be a bit uncomfortable.  It’s not really painful, just a bit…insistent.  This is another time when the breathing exercises can come in handy.  Although it was rather uncomfortable a few times, I didn’t have any bruising afterward.

The technician takes a series of images from multiple angles, so they move the wand around and dig it in to new uncomfortable places to get the various images.  This may cause them to re-apply more gel as well.  My technician also asked me to take a deep breath, hold it, and exhale at various points in the procedure.  (She only forgot to tell me to resume breathing once.)

I appreciated that the technician explained to me what she was doing as she was doing it, and didn’t mind me watching the monitor as she was working.  An echocardiogram allows you to see the heart beating, and the heart valves opening and closing, and it’s fascinating to watch.

I particularly enjoyed watching the Doppler portion of the procedure:

The first part of the procedure took about 20-25 minutes, and then it was time for the Bubble Study (a.k.a. saline contrast study).  My PCM ordered a bubble study because she wanted to determine if there was a hole in my heart.

In a normal heart, the bubbles that are injected for the test enter the right side of the heart through the vein and then go through to the lungs and are removed from the bloodstream before the blood circulates to the left side of the heart.  If there is a hole between the right and left sides of the heart, the technician can see the bubbles flow through the hole to the left side, where they don’t belong.

Don’t Panic!  The bubble study is less freaky than it sounds.  Nothing is injected directly into your heart.  (Also, if you do have a hole in your heart, and the bubbles leak though to the left side, it’s ok.  Your body will still process the bubbles safely.)

A second technician came into the room, we had the conversation about bubbles and why they aren’t dangerous, and she inserted an IV line into my right arm (since I still needed to lie on my left side for the procedure). The IV line had a valve, so that the tech could start and stop the flow of the saline contrast solution.

The second tech told me that at several points during the bubble study, I would need to do a valsalva maneuver, but she described it as “the way you would bear down during a bowel movement”.  Well, that’s not the way I learned to do a valsalva maneuver during aerospace physiology, so we had a conversation until I figured out that what they *really* wanted was an anti-G straining maneuver (except they wanted me to hold my breath during the maneuver, and not exhale in a big gust when they told me I could exhale).

With that cleared up, we proceeded with the bubble study.  The first technician would signal that she was ready, the second technician would release a stream of bubbles into the vein near my elbow, and they would tell me when they wanted me to do the straining maneuver.

Then we would watch the stream of bubbles rush into my heart.  The bubbles appear white on the monitor, and they are very obvious.  Sometimes the second tech would massage my arm a bit to help the bubbles flow faster or something.

The saline bubble solution felt a little bit weird when it first went into my arm, but then I didn’t feel it anymore.  The first batch of bubbles felt weird when it entered my heart – my heart seemed to flutter a little bit.  But it didn’t hurt, and I didn’t feel it with the subsequent bubble batches.

We repeated the sequence four or five times, until there was no more saline solution, and the first tech was satisfied that she had all the images she needed.  They were both very impressed with my straining technique. 🙂

Then the second tech removed the IV line, the first tech removed the electrode sticky pads, and they left me to wipe the gel off my chest and get dressed.

The whole procedure took about an hour, and I had no residual effects.  Turns out, the bubble study really *was* no big deal.

Also, since having a hole between the two sides is congenital (something you’re born with), I’ll never have to have this procedure again.  Once they’ve determined whether the hole is there or not, that doesn’t change and you never need to check again.

TL;DR:

Medical Procedures: What It’s Like To Get An EMG (Electromyography)

Raise your hand if you’ve got a bad shoulder (badum ching!).  Yup, me too.  Although I had surgery to repair it a year ago, I’ve had some lingering problems.

Since physical therapy (PT) hasn’t resolved the functionality problems with that arm, my primary care manager (PCM) ordered some diagnostic medical procedures to try to determine what’s causing the problems.  One of the procedures that was ordered was an electromyography.

Electromyography (EMG) is a diagnostic procedure that assesses the health of muscles and the nerve cells that control them (motor neurons).  According to the Mayo Clinic,

“Motor neurons transmit electrical signals that cause muscles to contract. An EMG translates these signals into graphs, sounds or numerical values that a specialist interprets…EMG results can reveal nerve dysfunction, muscle dysfunction or problems with nerve-to-muscle signal transmission.”

In my case, they were trying to determine whether a pinched nerve in my neck was causing the problems with my arm.

Electromyography is an outpatient procedure that typically takes about an hour.  EMG is often done in conjunction with a nerve conduction study (NCS), which I also had.  NCS is the measurement of “the speed of conduction of an electrical impulse through a nerve. NCS can determine nerve damage and destruction” (Johns Hopkins).

According to WebMD,

“Nerve conduction studies are done before an EMG if both tests are being done. Nerve conduction tests may take from 15 minutes to 1 hour or more, depending on how many nerves and muscles are studied.”

Since they were going to need access to my arm and shoulder (and trapezius, as it turned out), I wore a track suit with a tank top underneath. They asked me to take off the track suit jacket and lie down on an examining table.

To prepare for the NCS, the person administering the torture procedure asked me to move my fingers, hand, and arm in several different directions so she could determine her targets.  These she marked on my arm with a marking pen.  She fastened several electrodes to my hand and fingers with tape (see picture below), and proceeded to zap me with a machine that looked like a taser (but used less voltage, obviously).

 

This is not a pleasant sensation.  It typically wasn’t too painful, except when she applied multiple shocks in the same location.  The second or third consecutive shock in the same spot became more and more painful.  For the most part, she told me what she was going to do before she did it, which helped me prepare.  When she told me she needed to do 10 shocks in the same place, I knew two things: 1) It was going to hurt like hell, and 2) I’d better do the stress management/relaxation breathing techniques I learned at the base Wellness Center.

Breathing techniques, whether learned through biofeedback training or as part of yoga or meditation can be very helpful for managing pain or stress.  I use them whenever I am having an uncomfortable/painful/stressful medical procedure.  Of course, in this case, relaxing was a bit more challenging, since my body was also jerking from the shocks.  For some of the shocks, only my hand/wrist twitched.  But for some of them, my opposite leg jumped.  Several times I got a cramp in my arm muscles, and toward the end, I got a cramp in the muscles in my lower back.

That was part one.  Part two was the EMG.  “During a needle EMG, a needle electrode inserted directly into a muscle records the electrical activity in that muscle” (Mayo Clinic).

The needle is inserted into various muscles.  It didn’t hurt most of the times it was inserted, since it is a very fine needle.  It did hurt when it was inserted into the trapezius muscle.  Once it is inserted, the doctor taps on the needle, and sometimes moves it around inside the muscle as she listens to the signal.  As you can imagine, this doesn’t feel very good.  Then she asks you to engage the muscle.  You can hear an increase in signal noise while you are engaging the muscle.  This also doesn’t feel very good, as the needle feels like it is stabbing you more.

These tests may be done only on one side of your body (one arm, one leg, etc.), or they may be done on both sides of your body in order to compare results.  In this case, they only tested the problematic arm, not both, and the doctors were able to give me my results at the end of the procedures.

The good news is they didn’t see any evidence that I have a pinched nerve in my neck.  The bad news is that these diagnostic procedures didn’t help determine the cause of the problems with my arm.

After the tests: I had one righteous bruise, and I was tired for the rest of the day.

According to WebMD:

“After the [EMG], you may be sore and have a tingling feeling in your muscles for up to 2 days. If your pain gets worse or you have swelling, tenderness, or pus at any of the needle sites, call your doctor.”

“If you still have pain after the [NCS]:

  • Put ice or a cold pack on the sore area for 10 to 20 minutes at a time. Put a thin cloth between the ice and your skin.
  • Take an over-the-counter pain medicine, such as acetaminophen (Tylenol), ibuprofen (Advil, Motrin), or naproxen (Aleve). Be safe with medicines. Read and follow all instructions on the label.”