This page written circa 17 July, 2009.
On Tuesday we went for a day trip to Ruapehu. It was meant to be fine and sunny till late afternoon, but of course NZ weather does not do what the weathermen tell it, and it started raining and then sleeting by lunchtime. On the way back to the car I fell over.
Have you ever read that someone fell over in their kitchen and broke a leg or a pelvis and thought `gee, how can you do so much damage just falling over on flat ground'? Well, now I can answer that question: It simply has to happen very quickly. There is plenty of potential energy in 75kg held 1 metre off the ground to break the elbow and seriously bruise the back of a healthy man... like me, for instance.
I fell very suddenly when I stepped onto what I thought was snow, but that turned out to be ice. I broke the end off a bone in my elbow, and bruised and contused various back muscles by falling on a pointy object in my backpack. It was a very unpleasant experience and a painful one, knocking the breath and the sense out of me for a few moments. I imagine that it was fortunate that I was wearing a thick down jacket and fur hat that padded the blows. Now I have a huge cast on my left arm, still some risk that it will need a pin, enormous difficulty doing everything from eating to sleeping, a lot of x-rays and an ACC number. It is remarkably painful just getting out of bed. Either injury without the other would probably be much less incapacitating: My back would be less of a problem if I could push up with two arms and if I was not carrying a mass of cast. My arm might be less of a disability if I could bend to manoeuvre my clothes off single-handed. My body must be working hard, I tend to fall asleep in the middle of the day for 3 or 4 hours. This is going to be a very hard month.
The New Zealand health system treats accidents differently from other illness. The ACC provides "comprehensive, no-fault personal injury cover for all New Zealand residents and visitors to New Zealand". This greatly expedites medical and legal paperwork in cases such as mine. This is still no substitute for a little skelegro.
PS: Now 1 week after the event. Back starting to heal, I can briefly lie on my left side. Still hard to get above 2 hours sleep in one go. Tired out by 3PM if I start work at 9AM. Arm only aches if blood pressure suddenly rises, such as when woken suddenly by stabbing back pain.
PPS: Day 10. Referred to the orthopoedic registrar at the hospital by doctor at the clinic when he saw the first x-ray. New x-rays. Seems the bone has not aligned properly. Surgery tomorrow! Makes sense when he draws a full diagram of the joint, the tendon is set to pull the bone apart along the fracture. Accidentally discovered the local elbow guru surgeon---Thin Hong---but even private insurance is not useful as this is trauma and ACC and he is booked out for weeks. His receptionist was the most informative and useful person I have seen in this so far, though.
PPS: Day 13. Waikato Hospital turns out to be the equivalent or better of anything in SR. Both the orthopoedic surgeon and the anaesthetists were obviously on the ball, informative, competent people. Gave me plenty of options, and plenty of respect. Nurses were great, if not to look at. My elbow now has a plate and long screws in it. 36 hours later and I feel fine, if uncomfortable. Offered me lots of heavy painkillers none of which I needed or took, contrary to Kay's advice. Only two weak staff detected, and both had been given harmless roles.
PPS: Day 28, 11 August. I had my cast off today. The xray and picture of the scar are scary:
So far I have about half of the 180 degrees of movement expected in wrist rotation and elbow bend....
PPS: Day 28, 2 Sept 2009. I visited my GP, Dr French. I have pretty much full wrist rotation back, and have recovered from +/-45 to about +/-60 degrees elbow. The movement to straighten seems blocked by something hard, the movement to bend to 180 degrees seems to be stretchijng a tendon, so seems to be slowly improving. Worst aspect is that my skin is tight and does not slip over my bones as it ought. Resting my arm on a surface can be painful, sort of from the inside. Weird. I thought this worth mentioning. Dr French apparently didn't.
He did give me the surgeon's report, reproduced below. He gave it to me on paper. Seems sending email might risk a virus. Ah well, it is New Zealand.
The anaethetist was Kristen Matheson, and the "consultant anaesthetist" was Andrew Muncaster, I guess this was a training session, which is probably the way to get the best service! The surgeon was Troy Smithers, and the "orthopaedic consultant" was Jason Donovan, but I don't think I ever knoew he was there. Wonder what that all means? At any rate the words above manke Troy sound competent.
PPS: Day 71, 23 Sept 2009. I finally visited Mr Thin Hong, the Hamilton orthopoedic guru. He is your stereotypical surgeon, not the sort of man who looks as if he enjoys life at all. His said that the bone had fully healed (points to the X-ray) and I should use it fully. I got the impression that he was surprised that I had only just got a referral for physio. He said that any pain ought not to be originating in the bone, but in scar tissue, and that this must be broken away. He told me I should extend the joint with as much force as the pain would allow, "what movement you do not get back in the next few months you will probably never get back". Sensitive and helpful analysis. That was where I kind of lost the plot, scary. He has prescribed a brace that he says will stretch my arm to the max while I am asleep. I would be most keen to see if he could sleep with a machine that is pulling his joint past its natural extension point. In the mean time I have been stretching the arm... to no effect, as far as I can see. Discuss this with Anthea the physio tomorrow.
PPS: Day 73, 25 Sept 2009. I have now seen Katria, a lovely lady who works with UoW HRM to help people back to productivity; David who is an occupational therapist contracted to ACC who sees that you have what you need (basically to get off ACC's books though he would never be so blunt) and writes a "back to work plan"; my GP; and Anthea the physiotherapist. Katria and David were really good and sensible, but Anthea was the most helpful.
Anthea at Lisa Hansen's in Clarence St explained a lot about the physiology of collagen and the mechanics of elbows, and she benchmarked the elbow's range. I currently have about 30 degrees less flexion in my left compared to my right, and I am 28 degrees short of normal extension, the critical bit. She told me that she would expect patients to wind up with anything from 0 to 15 degrees loss in extension, and she thinks the brace ought to get me into that range. She explained why Dr Hong had prescribed the brace with the acronym "TERT" for Total End Range Time, meaning that now the collagen is hardening, to stretch the collagen I need about 8 hours a day with the joint at the maximum extension point, but as much movement as possible in the joint otherwise, hence "use the elbow as much as possible in the day, stretch it as much as possible when you would otherwise not be using it---at night". She suggested I make an appointment after about a week of using the brace, so probably a couple of weeks from now, to check progress.
As for my GP, I think it is time to find a new one. He acts like I am a nuisance not someone needing support and suggestions, and explanations. Regarding sleeping, I interpret his position as "hoping that the current program results in me getting sufficient movement back in my elbow to permit me to get a good night's sleep". His advice in the short term was to take a panadol when I wake up. (Thinking about it, that is the first time a doctor has actually told me the equivalent of "take two asprin and call me". You gotta keep your sense of humour here.) To be honest he referred me to Thin Hong pronto, and this got the ball rolling, but only after he pooh-poohed the idea.
PPS: Day 89, 11 Oct 2009. The arm brace arrived, and I wore it for the first time three nights ago. I went to bed at about 11:30 with the straps stretched tight, but by about 01:30 the pain had become sufficiently severe it was obvious I was not going to get any more sleep. I reduced the strain by slackening the straps until the elastic was barely stretched. From then on I managed to sleep for periods 30 to 90 minutes. I am not sure how much good it did to wear the brace with reduced force. Night two I put it on with modest force. I managed to get through 8 hours. I guess I slept in 90 minute chunks. Last night I punted for an in-between strain. I woke a couple of times in the following six hours, at which point the elbow felt very achy and I took it off and got 2 more hours straight sleep. I've been back at work full time, and reasonably productive, for the last two weeks, but if these last few nights are a good indicator I am not likely to be very productive while I am wearing the brace. Katria and Alison both mentioned a drug called amitriptylline. Quoth Alison "starting dose 10mg at night, increasing once or twice a week as required up to perhaps 70mg if tolerated and you don't get any hangover etc". Might be worth a try.
PPS: Day 102, 24 Oct 2009. Michelle at the physiotherapist's shop measured my arm the day the brace arrived, about 2 weeks ago, and recorded an improvement, but as I picked up the brace the orthotics lady did the same and got the exact same answers that Anthea had when I first went there (about 30 degrees loss each end), within a couple of degrees. We agree that the two weeks pre-brace saw no improvement.
I experimented with wearing the brace at night, very unsuccessful as noted above. After a while I discovered that I could tolerate a LOT of brace force when I was in the spa. I have moved to wearing the brace about half a waking day, then once or twice (if time permits) I wear it in the spa cranked out to the max. It does look straighter after that, but I recover on the bed, brace still on, till the strain gets to be too much. This regimen has been practiced for the last 8 or so days. I have the feeling that I am bruising the arm doing this, but that is probably as it should be, must ask at the fracture clinic next Tuesday. I also cannot help feeling that the arm "recovers" after these sessions. The day-wearing does not seem to have an effect, the spa-stretches seem to "wear off". Perhaps the net effect will be to push that collagen away as Anthea anticipates.
In the mean time sleeping is still very erratic. I had one good night's sleep in the last week or two, I remember it distinctly, it was a Sunday night! My work productivity is low, it's a good thing we are coming to a period without classes.
PPS: Day 105, 27 October 2009. Visited the fracture clinic again. More X-rays. The doctor was Troy D this time. He was very chirpy until I explained the sleep problem. That stumped him, really. After a while you could see that he was thinking "uh-oh, this is supposed to be a routine 10 minute session, and I haven't got a clue how to handle this". I think he is going for the "hope it gets better in time" plan. I have another appointment in late January. At least he acknowledges the problem, we put something vague and flexible on the ACC form.
PPS: Day 118, 9 Nov 2009. I visited Daniel at Anglesea clinic last week. A very holistic approach, this fellow had, and he was very thorough, but sleep was outside his sphere as well. I visited Anthea at Lisa Hansen Physiotherapy today. I am currently 16 degrees short of left arm in extension and 20 degrees short in flexion. We figured this was the action of the brace, as the extension is improving faster than the flexion.
One interesting point is that I had not worn the brace or stretched the joint for 60 hours before my visit. The logic behind this is that the joint perpetually feels very bruised... I guess it is... and I wanted a measurement when it was in its healed or at leastrested position. I observe that the joint straightens out in the brace, but seems to spring back out of it. At least it is not springing back fully, it seems.
I asked Steve French for a referral to a nose man. I figure much of the problem is that I do not sleep on my right side at all, and this is usually someting to do with noses. (I seem to know more about this that he does.) That request, added to three things about my elbow, caused the consultation to get billed to me instead of to ACC. You really have to know the system well not to get screwed by it! There is no doubt I need a new GP. I want someone who leaves me with the feeling that they are on my side, and who knows more than I do. Would you not think it fundamental consideration to brooch the subject of whether this might or might not be covered by the insurance that is covering the original accident? Duh. The government has noticed that ACC is expensive, and this new government, that's the one that is reducing expenditure on schools and universities, is trying to curtail ACC expenditure. You have to wonder on what they think it is good to spend money.
PPS: Day 153, 14 Dec 2009. Anthea measured my arm again, after a few days of no-bracing. I am back to full flexion, but still 15 degrees short of full extension. It looks like I have about 15 degrees loss, and the brace basically trades the loss at one end of the range for the other. On that basis, we are doing to try me walking around holding a dumbell, but not using the brace.
I also saw Hugh Litchfield, the ENT man, on the same day. He immediately observed that my nose was not symmetrical, and suggested the routine response, "Septoplasty & Cautery Reduction Turbinates", currently scheduled for 16 February, cost NZ$4,430. Hugh is a friendly and informative fellow, an older version of Hugh Grant. Although I had no need of such drastic measures six months ago, he reckons I will benefit on account of having the asymmetry and also on account of being a basically allergic kind of person. He may be right.
The procedure in NZ is to get pre-approval from your insurer. This involves a form with a section that has to be filled out by your GP, and have the referral letter and the specialist's response attached along with the quote. Thus I am back to Steve French. He turns out to be on holidays. I have left the form for his admin to pass on to Steve. Why do I have the feeling this will go wrong somehow? Plenty of scope.
There might be an interesting the response to this. There is a section that gets the GP to confirm that this is not going to be covered by ACC, the national accident insurance in NZ, there is even a spot to append the rejection letter. It might all go through without anyone questioning. Any informative response, however, would have to point out that this only arises because of the July accident, and if I was the insurer, I would do my best to stick it to the ACC. On the other hand, one might say that my inability to sleep properly would eventually have arisen as I got older, the nose wasn't itself injured in the fall. This will all be too much for these people to cope with.
PPS: Day 280, 20 April 2010. This semester I have a very high teaching load. The sleep problem persists, and has got worse since the A semester started. I typically wake up enough to see the clock and remember the time twice a night. As anyone who appreciates how things work in New Zealand would anticipate, the ACC do not want to know about my sleep problems, and my private health insurance consider this to be a "an existing condition". Most every situation in New Zealand is characterised by people striving to pass the responsibility on to someone else, and this is no exception.
I know that I breathe better through my right nostril, and that I customarily slept on my left side, this has been the case as long as I remember. I theorise that my arm now precludes my customary sleeping positions, and I roll over. This is pretty much what Hugh Litchfield said, though he might have been agreeing with me while using appropriate medical jargon. At any rate, in the last 6 to 8 weeks I have started waking up with my mouth open and dry, my tongue feeling like cardboard. Mornings tend to be something of a blur, given my broken sleep. The fracture clinic staff at the hospital did not have much of a clue about the problem, nor to whom they should send me. They are most interested in getting me off the "open cases" list. Ditto my GP.
I went back to the hospital and gave them the whole story. They promised me a referral to someone, but that turned out to be another (different) private ENT surgeon. The office of that surgeon, Tony Cecire, "returned the referral" to the hospital. Not sure what will happen next.
It seems rather unreasonable that this should only be a problem since the arm injury, yet neither ACC nor Tower considers it their responsibility! How does one deal with such things in the NZ medical system, where anything congenital is not covered even by private insurance? Hw does ACC avoid the responsibility of something that has only been a problem since an accident? I am not going to work myself into the ground by carrying on in the current situation indefinitely. I will be on study leave this winter, so it is not urgent, but another A-semester like this one is not viable.