Monday, October 29, 2007

It's the little things...

All this fanfare about Apple's new Leopard OS (10.5) has not moved me one iota. I suppose with all the time on my hands I could wrestle with installation on my ancient G4 PB, but I'd rather spend my time writing about other stuff.

Signs of Progress
My last couple of day have been interesting, as I find myself doing things (or trying to do them) that I haven't been able to. I sat up in bed two days ago, without realizing it was the first time without help. I stand on my two feet without a crutch or pushing up with my arms. I turn over on one side in bed, sometimes stopped by pain. I bend over to scratch my lower legs. I've even caught myself trying to take steps without crutches. Although I'm unconsciously pushing my limits, I sort of know I'm not there yet. I've found myself trying things first, then later asking my mother for help if I've failed. But putting on shoes is completely beyond me at this point.

On my own two feet
My reliance upon my mother for things hasn't bothered me much, and she's been good about letting me give things a go first before helping out. We took a nice walk out to the East river yesterday, and I was surprised at my endurance. I took a short video for my daughter, and was pleasantly surprised that I look pretty good.

Unfortunately, I won't have the luxury of her further presence here in NYC. I'm on my own! My grandfather passed away this morning, and mom had to fly back to Ohio to take care of my grandmother and other matters. He was very old, bed-ridden, and not very lucid. But he's in a nursing home and the impression was that he was stable. So my mother felt it would be OK to be here with me, despite complaints from my grandmother that her own needs were ignored. Now I know my mom is dealing with unwarranted guilt issues.

So, I'll continue here in NYC and hope I'm can progress to the point where I can be cleared to leave and attend a funeral. I'm not so close to my grandparents, so the death isn't affecting me as much. I need to focus on my recovery at this point, and if they need me I'll see if I can fly out.

I decided to show myself I can survive, so I somehow got my socks on (woohoo!) and slipped into my open back sandals to get some fresh air. I lumbered about 3 blocks to a deli, got some fruit salad and broccoli chicken, and returned to the Belaire. Folks were very nice about opening doors for me, and I didn't have any major problems. This was a big confidence builder.

OK, leftovers tonight, and PT tomorrow. One step at a time.

Thursday, October 25, 2007

Post Op Shop II

Since my last post, things have progressed quite a bit. I remained in the hospital room until yesterday (24 October) noon. This was one day longer than I expected, but mostly due to tiredness.

Crutchety Old Man
On 23 October, the PT person got me out of bed and on crutches for the first time. Crutch use isn't as difficult as you might think, but it takes lots of arm strength - more than I expected. Crutch use mimics the walker - move both crutches forward, then bad leg, and good leg. Though tough at first, I was able to go all the way down the hall to the PT room (~20 meters). Once there, I rested a bit and was then tempted with a short set of stairs (5 steps). I decided to give it a go and was able to go up and down with effort. Up with the good leg, down with the bad leg - that's the mantra for doing stairs. You use only one crutch, and one rail - lots of arm strength again. After stairs, I crutched back down the hall to my room.

Holy Crap
I was able to repeat the crutch feat later in the afternoon - around 2:40pm. But before that I had an ordeal the likes I had never expected when I had to have my first bowel movement. Often after surgery, you are dehydrated and the cocktail of drugs they give you leaves you constipated. When mother nature paid a visit to me, I had to wait 15 minutes before a nurse could help me to the commode. Then when I got there, the urge to go was great - but so was the pain. I had to make a lot of effort, then was scolded by the floor nurse in the middle of it. They were worried I would pass out. Well, after assuring them I would just 'let it happen', I was able to finish. The pain was excruciating, and I was exhausted. And it was embarrassing to have a nurse tech clean me up after. Aaagh! Perhaps this was worse than catheter removal.

Night to Forget
I had hoped to be discharged on the evening of the 23rd, but the constipation episode wore me out. I felt I could use the extra rest and attention. Unfortunately, the nursing staff was not particularly cooperative or quiet that night. I couldn't get pain pills when I wanted, and they bothered me when I was trying to sleep or nap on several locations. Perhaps this was a sign that they wanted me gone. :-) But more likely that they had a very busy night shift.


There was no doubt in my mind I needed to leave when I woke up on the 24th. I was tired of asking nurses to do everything (and impatient), and weary of my surroundings (except the great river view). My mother had already checked into the Belaire (hospital's hotel) and it sounded nice. Perhaps the thing that propelled me most was what I saw in the mirror when I got to the bathroom. After 5 days I desperately needed a shave, and my skin was very red around my beard where my eczema (dermatitis) often flares up.

The PT people came around again to confirm my first outpatient appointment, and even arranged for a sales person to come by with a 'reacher' - a device that helps you grab or pick up objects beyond your range of movement. I had one more PT session at 11am to practice crutches and stairs, then signed the paperwork for discharge. I had to agree to only take the prescribed medications (vicodan and enteric aspirin), and a number of other physician mandated restrictions. Then at noon, I said goodbye to my urine bottle and room, while a nice, tall blonde Russian girl wheeled me to the Belaire.

Reality Bites
Once in our 6 floor 1 bedroom apartment, it became clear that home life was not going to be a piece of cake. This realization came crashing down on me soon after I had entered the room. Although this hotel is run by HSS for families of patients needing extended care, it seems to lack things required by disabled or recovering patients like myself. No elevated toilet seat or chairs, low sofas, and a too soft bed. I can't really complain, as this will get paid for by someone else eventually. But you would think they'd pay more attention to needs of the disabled.

I also found that things are quite different when you aren't flat on your back in a hospital bed. You have to walk to the bathroom, stand while washing, move several meters to bed, chair, couch, etc. on crutches. If you change clothes (or pull up your pants), you have to use the reacher (or get some help). Fortunately, my mother helped me with many things, including going out to get meals, cleaning clothes, pushing chairs, picking up dropped items, reaching hard to reach places, lifting my operated leg, etc. Hell, I can't even get to the phones from the couch or bed in a few seconds.

Wow. If I was alone somewhere, I'd never make it after release from the hospital. Now I understand why hospitals in Japan keep you in a rehab facility for nearly a month for full hip replacement.

Monday, October 22, 2007

Post Op Shop

On the Other Side
My surgery was at about 10:30 AM on Friday (19 Oct), and I woke up after about 1pm. It was a little weird getting my sensations back bit by bit, and I didn't relish the lack of control. However, in a few hours I had all my major senses and not much feeling below the waist.

They kept me in the post op recovery room for 27 hours, because of lack of bed space in the hospital. Everybody wants their recovery on the weekends, maybe. But the nurses in the recovery room were very nice and helpful - pulling me through some confusing times. I was fortunate, in that I had little or no post operative pain. When the PT got me up for walking, I had some pain but was able to take a couple steps with a walker.

I was struck by how many tubes and wires were attached to my body, to either monitor body functions or deliver some important substance to my body. I had a saline IV in my hand, an antibiotic IV (wrist?), a PCA epidural in my back, sedative drip in my jugular vein (neck), 3 EKG electrodes on my left lower rib cage, a catheter up my schlong, oxygen tubes up my nose (photo), a bag to collect fluids from my surgical incision, and two pressure cuffs on my lower legs to encourage circulation (minimize chance of clots). Maybe I've forgotten something? The only thing left now is the cuffs, which pleasantly squeeze at intermittent times with a 'puff' sound. These cuffs actually brought the first sensations to my lower legs - making my toes tingle, then feet, then ankles, calves etc. Removing most of these things was often painful - as they were taped to my fairly hairy body. Rip!!

The cocktail of chemicals and pharmaceuticals in my body was also impressive. I had/have blood thinners, clot busters, pain killers, anti-inflammatories, antibiotics, stool softeners, vitamins... I've probably omitted something. The PCA epidural is a machine that delivers pain blockers to space between vertebra in my lumbar region. So, sensation from pain receptors at or below the level of the epidural were minimized. PCA refers to 'patient controlled anaesthesia'; I had a device with a button that I could press to deliver a pulse of meds to the epidural. While in post op, the machine delivered meds at a slow rate, so any pressing I did just upped the dosage temporarily. When I moved to my room, the auto drip was off, so I had to pump to get the drip. At that time, however, they also started giving me Vicodan and eventually weaned me from the pump altogether. I now take Vicodan every 4-6 hours (when I ask) and think I've cut it to one pill instead of 2. However, PT may push my dosage up again.

Room with a View
They moved me to a room at 4pm yesterday. I shared it for one night with an amazing 66 y.o. guy that had two THR (one a revision of a BHR), and was in such great shape he was ambulatory after 3 days. The room is on a remodeled floor (8th), and very spacious. I count eight window panes over looking the East River. Both beds face the river; I have a great view of the lights at night and the sunrise in the morning (below). Some aspects of the layout and equipment are not optimal, but these things could be worked out with little effort. Every morning with breakfast, they bring you a flower that you can stick in a little vase - gives you a sense of how many days you've been in the clink. Rooms are provided with free wireless internet of dubious quality, and you have to pay $8 a day to use the TV. After my roomie left this morning, I've had the room to myself - so I could really enjoy TV at normal volume levels.

I was switched from liquid to solid foods Saturday evening. Speaking of food - the quality is OK (and quantity), but the service is erratic. I remember writing down preferences before surgery (low lactose) - but apparently these have been forgotten. We are given menus with choices to circle. Unfortunately, some mental midgets on the serving staff are unable to remember to give me what I asked for, despite having highlighted my selections and attached it to the meal tray.

Physically Challenged
Today was day three - and my first full day in the hospital room. In the morning PT session, I had some light-headedness, so I didn't walk any. I felt embarrassed and frustrated - and also worried. I think my Vicodan wore off, as the pain was prominent. Or it may have been related to the fact that I didn't sleep well after they removed the catheter on Saturday evening. The sensation was annoying, and I couldn't figure out if things were moving or staying. The threat of replacing the catheter if I couldn't void put a lot of pressure on me to go before midnight. It was like learning how to pee again, but with lots of irritation. And my best friend is a plastic bottle between my legs that I fill up religiously. Maybe this has been the toughest thing to deal with so far, but I'm happy to report that my plumbing is nearly normal at present time. :-)

After an hour's nap and lunch (with more omissions), I felt stronger. When the afternoon PT person came, I rather easily sat up on the bed, stood with the walker, and made it halfway across the room and back. I think the timing of my pain pill around lunch also helped. Later on, after my wife and mother arrived - I sat up on my own, and with some help got to sit up on an elevated chair so that I could watch some TV from that position. Well, that was my hope. But with both gals yakking and fussing, I didn't see much. That's an easy price to pay when someone that is willing to bring you a decent cappuccino and donuts.

They also have taken my bandage off, and I've seen my incision with the help of my digital camera. It's pretty ugly, and seems to be covered with some sort of papery material. I don't quite see stitches or staples, so I'm not sure what keeps it close.

The care here at HSS has been excellent for the most part. I'm a little disappointed with myself that I can't make more physical progress. It will come, but I wish I didn't have to push myself so much to get over the pain or be so reliant on pain meds. My MD told me to try sitting to motivate me to get up more. I think it helps. I really want to be up and about on my own. And with bowel issues coming in the next day or so - I have added motivation. If I have the time or energy, I'll give an update in the next few days.

Well, the lame ALCS game is nearly over, and like the Indians, I'm out of gas.

Wednesday, October 17, 2007

Hip to be spared...

This post is a bit nontech, but perhaps many people will be interested in what I am experiencing. I left Tokyo on 14 October for NYC, and will remain in NYC a few weeks. I'm getting my hip joint fixed.

I've always been physically active in my adult life, but had to stop nearly everything 2 years ago because my right hip was giving me problems. This meant the end of biking, running, hiking, basketball, raquetball, and my passion - ultimate frisbee. It was a hard pill to swallow, but the pain and the diagnosis by a Japanese doctor indicated the hip joint was failing. I was told to lose weight and bike or swim to keep in shape, and hope to delay joint replacement until my 50s (I was 41 at the time).

Well, in the two years that followed I couldn't do much exercise because of the excruciating pain. Biking was impossible. Swimming was OK, but the distance I had to walk to do it was often difficult. And with my job standing and lecturing, as well as use of trains for my commute - things deteriorated. Adding a few pounds didn't help either.

In May of this year, the pain was so bad I went to a nearby clinic to see an orthopedist, and he told me the joint was in its 'terminal' phase, and that my left one was not in good shape either. You can see the Xray at right, bad hip is on the left side of the photo.

I started looking for local solutions to my problem - in Japan. I went to a reputable orthopedic hospital in Shinjuku and was told they could do total hip replacement (THR), and use a ceramic joint fitting. Unfortunately, THR is very destructive, basically cutting off the entire top quarter of the femur. And THR's may only last 10-15 years, with revisions requiring more bone destruction. Usual candidates for THR are in their late 50s or 60s, but for someone my age I just couldn't see whacking off so much bone. Unfortunately, this is the only technique readily available and in common practice in Japan.

You can see a THR example below left. This image is from Dr. Edward Prince, M.D.

Fortunately, there are other alternatives to THR, namely a relatively new technique called 'joint resurfacing' that was tried (and failed) in the 1970's, then completely revamped
about 10 years ago. The original successful version of joint resurfacing is the Birmingham Hip Resurfacing System (or BHR) developed by Derek McMinn in Birmingham, England. BHR was in use in England from 1997, and was FDA approved for use in the US in May, 2006. There have been other similar systems developed (Cormet, e.g.), but BHR seems to be the most commonly used. The advantage of BHR is very clear for younger patients: less bone loss, more future options, higher potential levels of activity. You can see from the below right BHR photo (from Orthoworks, UK), that the implant size is considerably less - a femoral cap over or replacing the ball and a matching cup inserted into the pelvis. There are reports of many athletes having this surgery, including Floyd Landis, and they are able to continue their activities at similar or higher levels.

Of course, there are potential problems with BHR, and with only 10 years of supporting data - there are a lot of questions that remain unanswered. The first of these is longevity. We just don't know the lower or upper limits of lifespan of BHR implants. The other issue is the potential problems from metal on metal joints releasing ions into the bloodstream. BHR uses Chromium Cobalt, and there isn't enough long term info to determine its effect. Another risk involves stress on the femur neck. Therefore, the placement of the implant is critical. The angles must be carefully worked out so that stress doesn't exceed the bone's capacity. This also means that the patient needs to have good bone mass to support this implant, compared to THR.

Fortunately, I meet all the criteria for BHR and am at the young end of the spectrum (average age is 48 years). Unfortunately, I had to look outside of Japan. Yes, there were a few places offering BHR in Japan, but the replicates of BHR performed were very small by those surgeons. Given the importance of positioning the implant correctly, a surgeon's number of BHR surgeries (as well as successes) is critical. BHR is relatively common in Europe, with Dr. Smet in Belgium having the most experience. There are actually two or three UK trained surgeons in India performing BHR (Dr. Bose in Chennai the most senior of these), and the cost of doing that surgery is very low compared to the US. Medical tourism to India is very popular, as a result of such low costs.

Given that US surgeons have only had limited time for BHR, only a few have had much experience, including the trials leading to FDA acceptance. Since my insurance was willing to pay for nearly all expenses, I decided to look for surgeon in the US with experience. When I combined this with a comparison of the best hospitals for orthopedic surgery, I came up with one particular choice: Hospital for Special Surgery (HSS) in New York City, and Dr. Edwin Su. HSS has the lowest infection rate in the country, as well as the highest ranking by US News and World Report. Dr. Su has nearly 400 BHR cases to his credit, and I liked the fact that he is publishing research papers on his surgical work. Plus, I was able to find and email him directly - and he answered me in short order. So, about 2 months ago I began making arrangements to come to NYC for my surgery. There have been many hurdles, but Dr. Su's office staff made many efforts to help me out. The hardest part for me has been separating from my 11 month old daughter and wife for a few weeks. But after meeting Dr. Su and the hospital staff, I know that I made the right choice. I'm in very good hands. These are quality people.

So, I go under the knife on Oct 19th, and will probably stay in NYC for at least 2 weeks after for rehab. I'll probably post more of my experience in the future. In the mean time, I will try to see some of NYC.

Sunday, October 07, 2007

iPod Touch in Da House

A couple days before my pre-ordered 16GB iPod touch was supposed to ship (28 September), Apple Japan sends me an email stating my iPod would now ship on 10-14 October, and arrive 15-19 October. This ticked me off, as I've already heard the Touch was in Apple stores here, and I will be going to the US for 4+ weeks on 14 October. Well, before I could call the English line for Apple Japan and rip them a new one, I got another email saying that the iPod had shipped and was on its way (29 September) and could be expected on the original ETA - 4 October. Whoa! Even got my くろねこ tracking number. I was pleasantly surprised when it arrived on 2 October - two days early! Woohoo!

Unboxing the Touch

The shipping box was plain old cardboard, with the packing slip taking up most of the surface. Nothing much to see here, move along. Cracking open the box shows the slick Apple packaging cradled in a tomb of cardboard.

Here is the compact box in shrink wrap. I often wonder if Apple should go back to it's more enviro-friendly plain cardboard packaging, as this seems quite wasteful. After clipping the shrink wrap and peeling it off, I get my first look at my new iPod. Note the generous soft foam padding in the box lid. The box is double-layered dense cardboard. The iPod itself is sitting on a black plastic tray (not shown) which supports it above the contents below. More waste.

The Touch was generously smothered in a layer of plastic film, front and back. In the back view you can see how the film flaps were overlapped. I also got personalized engraving (not sure why I did this now), but it's obscured by the flash. I remember how my 1st gen Nano got scratched easily after I took this off. I was a bit hesitant to remove it, to be honest.

All the instructions (all in Japanese) came in the thin black box (right, above) and there were only two pamphlets (above), with the requisite sheet of Apple stickers, and a small slip of paper with websites with contact info. One of the pamphlets was info on compliance and addresses in various countries for support. The other pamphlet was a small fold out pamphlet with slick color photos and text telling you the general features of the Touch, with very little info on how to use it, and of course the requisite URLs to download the latest iTunes, and the pdf user guide. This was a bit surprising - no full manual at all included. I think it's fine to minimize paper waste, but this slick fold-out is more promotional than practical. Maybe I wouldn't mind the pdf 'only' manual if I could actually refer to it on my iPod Touch whenever I need to.

At left you can see the thin white plastic pack that contains the Touch's accessories. Inside there is the USB cable, Apple earbuds, dock adapter, and a supposed stand.

-The USB cable is crappier than the one I got with my 1st gen Nano. The 30 pin iPod plug is half as tall as the one from my Nano and lacks the side buttons to release it from an iPod. No plastic plug covers either, but let's call that a positive enviro move.

-The dock adapter apparently works with Apple's docks (but not on my 3G iPod dock nor my old Altec-Lansing portable speakers).

-The Apple earbuds I didn't try - they are still in the shrinkwrap. I'm not bothering with those things anymore.

-The stand is a clear plastic thing that has a groove you for the Touch's edge. It's kind of like one of those plastic things used to keep photo frames standing upright. Although I suppose someone will say that its elegance is its simplicity, I would say that Apple could have done much better for the price we paid. The big problem with the stand is that you can't have the Touch plugged in to the USB cable unless it is sitting in landscape mode. Given that the menus and controls are all in portrait orientation, it's kind of stupid. I suppose this allows you to use the Touch as an digital photo frame or table/desktop movie player...

-Apple was kind enough to include a 'polishing' cloth. I think it was under the plastic tray, but I can't quite recall. This cloth is supposed to help you control the fingerprints and skin secretions that will make your shiny iPod touch look like a subway train window. Unfortunately, the grain on the cloth is too coarse to actually polish anything. I had to use a damp microfiber cloth instead (came with my PSP).

Using the Touch
I'd like to post in more detail at some point, but will try to be brief here. Without a physical manual to refer to, I've found myself just learning by doing. Yeah, I could read the PDF file on my Mac and fiddle with the Touch at the same time. Unfortunately, I mostly have time to fiddle with the Touch on the train or while I'm falling asleep in bed. So, I probably am missing some things.

Browsing photos and watching videos is a joy. The screen is awesome (no bad screen for me) and the quality of video play is at times stunning. I love being able to zoom up on photos and see the grain. Getting video content on the iPod was not difficult. I had some Frederator video podcasts sitting in my iTunes library, and there is plenty of free video podcast content out there. (National Geographic rocks!) To convert some of my digicam videos, I use the free iSquint. I prefer to save them as TV format (this app was designed for the dinky 5G iPods), and the quality is quite good. Better quality would mean less space on the Touch. Loading photos was not so easy. I wasn't able to use my Pictures folder and choose folders within it to sync picture from. iTunes chokes on this - likely because of the number of photos in that entire folder. So, I'm using a nested folder with copies of photos I really like. Sure, I could sync with iPhoto - but I haven't cataloged all my photos there as yet - and not sure I want to.

The biggest gripe I have with the touch is that when I scroll around through menus (coverflow, music lists, etc) or even around a web page - I somehow inadvertently click on a link or button. This is annoying and I would think there was a way to adjust the touch sensitivity or the 'click' sensitivity. But there isn't. Yeah, some bozo will say that I need to practice using it more - but it's more than that.

The second biggest gripe I have is the one everyone has - no way to control music without taking the damn thing out of my pocket and firing up the screen. This is ridiculous.

The third biggest gripe I have is the inability to open a link into a new web page. Yes, you can open a second web page, but not open a link on a page into a new page. Pain in the ass.

I'd like to say more on using the Touch, but this post is too long already.

I will close by mentioning that I did find a decent pouch for the Touch. Given this product is just released, there isn't Jack for accessories available. I first put it in an old Timbuktu 3G iPod nylon case. But this was too bulky in my shirt pocket, and didn't fit too well. Then on a whim, I poked around the camera section of Yodobashi (after not finding anything in the Mac section). I found this little microfiber cleaning cloth bag made by Hama that just fits my iPod touch and is thin. Only ¥950! I remember seeing self cleaning iPods bags on Waterfield Design's site, but this one is nicer - has a draw string. This product is available outside Japan, and is made by a German company I think. And it works well, self-cleaning the iPod while it's inside. You can see what it looks like here.