1. Verklan, M. Terese PhD, CCNS, RNC

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Something happened on Thanksgiving Friday that has never happened to anyone in my family, including me-I broke my left fibula. I was playing in one of my favorite ice hockey tournaments and things were so exciting. It was 90 seconds into the first game of the entire tournament. I was on the second line and as I stepped out onto the ice, I felt my foot go one way and my entire body go in the opposite direction!! It is amazing how fast you can think in a split-second. "This is bad-if only someone would stop me falling right now, I'll be ok." Of course, no one did because no one noticed that I was going down. The game was stopped in a flash and people skated over to help me up (apparently I set a tournament record in getting hurt 0.3 m (l foot) off the bench!!). Oh, boy, did it hurt.


They placed me back on the bench and the pain disappeared. My captain asked if I was ready to go back on the ice and I said sure!! But I couldn't even stand on the leg, so I sat down again. He asked me again at the beginning of the second period, and I said sure!! Again, I had to sit down. I was carried off the ice, and being the "poster child for independence" as I was later called, I waved off the ambulance, got help getting to my car, and drove myself home. I was sure it was only a sprain and it would be so better in the morning. I hopped into the house, and it kinda hurt. The leg hurt going up on a pillow in bed, but not really bad for a sprain. In the morning, I stood on it and felt the bones move. Okay, I now believe it is broken, so I drove myself to the emergency department. So, now I am in the healthcare system. And I was a quite surprised that I did not know what to expect.


Within the hour, radiographs depicted a spiral fracture. The leg was wrapped and I was to see the surgeon on Monday. I shook my head when asked if I knew how to use crutches and received a brief demonstration as someone was asking me about my insurance coverage. I was placed in a wheelchair and taken to the accounting area to sign some forms and pay my deductible. A nurse wheeled me to my car, helped me and the crutches get settled, and off home I drove. Later, friends educated me on how to properly use the crutches to walk and go up and down curbs. I was not on any medications and I thought I was listening well, but maybe not?


When the orthopedic surgeon found out I was going to continue to skate competitively, he planned to reinforce the bone with a plate and 7 screws (the radiograph is fabulous!!). He sent me to the hospital to have blood drawn. The electrocardiogram sorta threw me off-guess he thinks I am old or is that routine now? I answered some health-related questions and was told to report in the morning at 7 AM and to be sure that there was someone available who would drive me home postoperatively, or I would not be released. Really? So feeling pretty good and completely painless since the leg was properly wrapped, I went to the university because I had to teach (the surgeon had wanted to operate that afternoon, but I told him I had a full agenda already, could he please operate tomorrow!!)


The next morning upon report to the hospital I am told my room is ready-room!! I had pictured going into some kind of locker room and changing, sitting in a "waiting" area and then changing back into clothes later. Off I went to my lovely room, and after verifying who I was and the intended procedure, I was instructed to change into this blue gown. How I loved that blue gown-it is called "Bear Paws" and has an opening into which a tube injects warm air that flows all around you. It had a wonderfully immediate relaxation effect. The nurse said that research indicates that warm patients have far less postoperative complications and improved outcomes. Ooohhh, where can I buy 50 of these for cool winter nights on the couch ... it was dreamy. I was so comfortable that I did not realize the operation was now hours behind schedule.


The anesthesiologist came in to tell me the medications he would use and that he would place a nerve block to make the operation and recovery more pleasant. Sounded good to me. I was well sedated when the block was being placed-I needed to be reminded to breathe at times!! And I vaguely remember being wheeled to the operating theatre. I woke up in the postanesthesia care unit with a nurse sitting next to me. I was relaxed in my nice warm gown, but was in excruciating pain. She had given me fentanyl and morphine, and then gave me meperidine (Demerol), which had no effect. The anesthesiologist came immediately and bolused the nerve block, providing a wash of immediate relief. I just felt so tired. I asked the nurse if I could sleep. She said yes and as I started to close my eyes, I could hear the cardiopulmonary monitor alarm. She shook me and said, "Take deep breaths!! Take deep breaths!!" After a while, I was returned to my room warm and pain-free and oh, so comfortable. My friends were given instructions on what to look for in the way of adverse events, and I was discharged home in their care.


Needless to say, I went to bed and slept pretty much through the night. Feeling fantastic, I went to my computer to work and after a while, I noticed that my nerve block catheter was leaking. My friend helped me change the dressing, but soon there was more leakage. I told the anesthesiologist about the problem later that day, and he told me to get off my butt and lay down-that I was sitting on the catheter and that was the reason the medication was leaking. I had pictured the catheter running down the leg, but in actuality, it was positioned to provide medication at the sciatic nerve-I really only know things about infants and fetuses!! As instructed, I was to pull the catheter the next afternoon and I was astounded how long it was. Being the compulsive neonatal intensive care unit (NICU) nurse, I examined it for any breaks, looked to be sure both ends were intact, and stopped short of measuring the darn thing. All the while I was thinking, the only instruction I had was to "pull it out." A layperson would not know to check for breakage or complications. I was surprised that open reduction and internal fixation of the left fibula is now outpatient surgery!! Patients used to be in the hospital for ages when I was in nursing school. And here I am complaining that I have a crutch in each hand, and I can not carry my cup of tea to the chair!! Wow-orthopedics has come really, really far.


Later that day, I sat with my foot up looking around the room and thinking about what I had in the house that I could possibly use as a "knitting needle." My limited experience with orthopedics was in my undergraduate nursing program and a childhood friend who had broken an arm. I remember people complaining about how terrible the itching was and how they worked like crazy to get at the offending area. I did not realize that I was not itching because I was so focused on how was I going to have tea!!


I returned to the surgeon for my first postoperative visit, bringing my "boot" as instructed. His assistant removed the ace bandage and to my amazement there were 3 pieces of a formed fiberfill "cast" covered by some white soft material!! I did not even have a cast!! Then I remembered that I did not experience any itching at all!!!! Incredible. Both that I did not have the expected itching, but more importantly, you would think a nurse would be able to distinguish between a plaster cast and a soft material at the end of a leg!!!! I didn't know enough to begin to ask real questions about the healing process and forgot the 1 or 2 questions I did have when the bandages were unwrapped.


In physiotherapy, we discussed the goal of having me skate in a national ice hockey tournament in Las Vegas in 6 weeks. The physiotherapist was not hopeful, but I planned on working very hard. After all, I was walking without a cast or crutches 12 days after the surgery-I could do anything. I rehabbed hours a day, and 4 weeks later, I was on the ice skating without any pain at all. Vegas here I come!! Unfortunately, I was at a public skate with levels of ability ranging from "I can't spell skate" to "I think I'm a pro." A child ran into me, grabbed the fingers of my right hand and ripped the flexor tendons off the thumb, and first 2 fingers-goodbye Vegas. Today, I am almost well enough to play in a tournament in March.


Well, the point of this story is seeing the hospital, nurses, physicians, and health-related routines in a whole new light. I have been in the NICU so long, it is like my second home-I could walk blindfolded through the halls and tell you what is anticipated to happen in a myriad of circumstances. Take a good look at how parents walk through the door the first time they visit their infant in the NICU. All of their movements are tentative, eyes are wide open and scared, "routine" noises startle them and they do not remember the basic information regarding the radiant warmer, unit protocols, or how to contact the nurse. If I had not seen that look a million times, I would swear that I received no instructions on how to use crutches from the nurse in the emergency department. The parents are joyful when they think of the progress their infant has made. I was like that the first weeks of physiotherapy. My range of motion was getting better and better every day. After 6 weeks, the physiotherapists told me I was not progressing anymore. How could that be? I am working hard-there has to be more exercises we can do. I was told that I could not expect the limb to be "perfect" again. Just like our parents thinking that their infant will leave the NICU looking like a "Gerber" infant after we have gently, and then, not so gently, have tried to tell them that their precious one will have serious, ongoing complications that may never get better. I still have some questions-oh, did I ask that before? I understand the frustration much better now. I can walk, run, jump, skate, bicycle, in essence, do everything like before, but it bothers me that the range of motion in the left ankle is not like the right. I am still working to increase the mobility. Unrealistic expectations? Hmmmm ... How many times have I (we) thought that of the parents/families that have had the same thoughts of their neonate?


M. Terese Verklan, PhD, CCNS, RNC


Associate Professor and Neonatal, Clinical Nurse Specialist School of Nursing, University of Texas, Health Science Center at Houston