The great terror of surgery and prescription drugs

Years ago, my uncle once had nasal surgery to correct long-term damage caused by chronic infections that had gone on for years undetected and uncorrected.

Amazingly, when the surgeon reached the top of the nasal cavity, he discovered a layer of necrotic tissue on the lower portion of my uncle's frontal lobe. That is, the frontal lobe of his brain. Yes indeed folks, the nasal passages are that close to the center of reason in the human mind. The surgeon felt the situation was serious, and could not be left uncorrected. He literally scrapped the dead tissue off my uncle's brain.

The surgeon was nervous. His mission was to correct all damage done by chronic infection. Thisnecrosis was caused by the chronic infection. This procedure was covered under the mission statement. Necrotic tissue anywhere in the body is serious. On the brain, it is much more serious. Still, scraping a man's brain is no trivial thing. The surgeon was concerned about potential memory loss.

When my uncle came out of the anesthesia, the surgeon explained the situation, and asked him point blank: Have you forgotten anything? My uncle responded in his classic Sagittarian manner: "How the fuck am I supposed to know the answer to that question?"

This story was on my mind when I had my two recent knee surgeries. Brain damage occurs when they give you anesthesia. That is a fact folks. If you think Tokyo Ice Tea will kill a few brain cells, try Propofol. That really kills some cells.

I pride myself on my memory. I used to joke, in the words of Commander Data, that I retain every fact I am ever exposed too. That's not much of a joke, according to my brother. He tells people, in deadly seriousness, that this statement ain't far from accurate.

My brain is my one sterling asset and attribute. As a dude with no less than four (count 'em) four Virgos on my natal chart, you know I am all about the brain. I did not much appreciate the notion that Propofol might do some damage to this one marvel I have been given.

Those surgeries occurred in October of 2009 and January of 2010. My knees were not fine, but my brain seemed fine after that. I did some of my best writing in the prelude to the draft. I am sure Billy Devaney would disagree with that statement if he ever read any of it, but the "draft Bradford" campaign was horribly vexed by my writing. They still regard me as their arch enemy, although this is something of a misunderstanding.

Recently, I have had two moments at work that have caused me to wonder whether I did experience brain damage leading to some memory loss as a result of the propofol or the hydrocodone.

We had a complex situation at work related to networking where our network guys made a bad call. They wanted us programmers to use IP addresses in our code rather than DNS names. This recently exploded in our faces, creating a number of chronjob failures when network changes occurred due to Dynamic IP assignments.

When this happened, my bud Kapil chastized me for not speaking up in the meeting when the plan was laid out.

"What meeting?" I asked him.

"The meeting we all went to! The meeting where I fought them and you were silent."

I doubted Kapil's story. I almost never get invited to meetings. They don't like me in meetings. As a blunt, tactless Virgo, who never misses any error, I blow up a lot of the best laid plans of mice and men. I had no recollection of ever being in such a meeting. I knew I would have blown them up pretty good if they had thrown the idea past me.

A few days ago, a couple of other dudes in our section backed Kapil's version of events. They claimed I was there, and I was silent. I still doubted them. I would remember that, and I was sure of it.

Then came the scary event. The Feezone Archive. Inquires were made as to whether the Feezone Archive was running. "The what?" I asked. "The Feezone Archive" they responded. I had no recollection of what they were talking about. I mean zip, zero, nada, nothing.

They claimed they had a record that the Feezone Archive project had been assigned to me. I looked into it. I found a database called "Feezone Archive" on our main production SQL Server. I found a project in SubVersion called "Feezone Archive". It was written in C#, one of my trade marks. It was exceedingly brilliant, too. I was impressed by the code, and I don't impress easy.

Words cannot express the horror I felt for a couple of days after that. Yes, this was a trival task. Yes, it only looks like I worked on it for 2 days--this according to SubVersion audits. Apparently the job was done some two years ago by July 7th, 2008. Yes, it worked, and yes they dropped the ball by not scheduling the job. But still, that is beside the point. I had absolutely no memory of it, and I mean none.

I kept hearing the words of the great Peter Gabrial song "I can't remember."

I don't remember, I don't recall

I got no memory of anything at all

I don't remember, I don't recall

I got no memory of anything

-anything at all

This has never happened to me folks. Never once in my life have I forgotten a project I worked on. I can still tell you about the trivial password synchronizer I wrote for Wellpoint Pharmacy Management which made Mainframe and Sybase passwords identical. I can still tell you about stupid shit I did with VB5 for Transamerica in 1997.

I am horrified. You never know what cells the Propofol will take. You never know what you are going to lose when you go under the knife. I am grateful that the propofol only took this memory, if such is actually the case, but what else might I have lost? Like my uncle, I cannot answer that question.

All of this worries me greatly. I am going to go under the knife again sometime in October. This is going to be a longer and more involved, more dangerous surgery. I wonder about it. It worries me.

Vicodin in the news

Vicodin, Vicodin everywhere but not a drop to drink...

If I have seen it once in the news, I've seen it 50 times in the past week or two. Of course, there is the horrid case of Sean Payton and the Saints. We've been reminded about Brett Favre's Vicodin thing. Then there was Kevin Ellison. Then there was the former Miss Russia Anna Malova. NFL bust Ryan Leaf got hammered for Vicodin possession recently. Then we were all reminded that Dr. House M.D. loves Vicodin. I just saw Bad Lieutenant, Port of Call New Orleans. For the Bad Lieutenant, it all began with a back injury and a prescription for Vicodin.

Then they dropped the bomb-shell: the mixture of 5mg hydrocodone and 500mg of acetaminophen (Vicodin) is the most prescribed drug in the United States of America. Surprised the hell out of me. Then again, I was not surprised.

I heard a lot of people were using this shit. For the life of me, I can't understand why. This always goes back to the narcotic resistant thing. I have a nice red laminated 8x5 inch card in my medical file at Dr. Bachner's office. On that card, you can read the words printed in large bold black letters "Narcotic Resistant Patient".

Resistance does not equal tolerance. Tolerance develops over a long period of abuse. Resistance is genetic, and it means you flat-cold don't respond to narcotics the way others do, and you never will. I have a different Mu receptor than you do. My DNA encodes a different amino acid sequence there. That is all there is to it.

Vicodin didn't work well for me at all. I was in a hell of a lot of pain after my first surgery. It struck immediately as I came out of the Propofol. On the surgical table I could feel the burning, itching, throbbing, swollen, cut pain in my right knee. My anesthesiologist was stunned. He though the Demerol he had given me would be sufficient. It didn't work.

He ordered another dose of Demerol. As the nurse injected me, she asked me if I could feel it. That seemed like a strange question. "Nope" I answered. She was shocked. She expected to see my eyes roll up in the back of my head and hear me let out a grunt of ecstatic pleasure like "Ahhhhhhh..." This is how most people respond to narcotics injected into their blood stream. Not me.

She asked me a moment later if the pains was gone. "Nope, I can still feel it throbbing and burning. It hurts a lot." Unbeknownst to me, that was my second shot of Demerol. She was amazed. I withstood a second shot of Demerol with little or no effect shown. Eventually, about 15 minutes later, the pain began to die down.

That is perfect example narcotic resistance for you. No head rush. No euphoria. No immediate relief. Delayed onset of the analgesic effect. Shorter duration of that effect. The doctors cannot control post-surgical pain using the weakest narcotics, which is the normal convention. Demerol and Vicodin weren't worth poop-squat to me.

Vicodin didn't do much for me after the surgery. I was in a lot of pain a few hours after than Demerol shot. I slept like crazy, partially to get away from the pain. It was a troubled sleep. It was not a restful sleep. I would be awakened many times by eruptions of 'break through' pain. I would take the Vicodin. It didn't do much for me. It made it a little better. I still felt plenty of pain.

For me Vicodin = weak and infective.

The second time around was entirely different. The Doc knew what he was up against. When I came out of the surgery the second time, Dr. Bachner ordered a double-dose of Dilaudid (dihydromorphinone). Dilaudid is 10 times more powerful than morphine. Demerol has only about 20% of the strength of morphine. Dilaudid is 50 times stronger than Demerol. He rolled out the big guns. He wasn't fucking around.

Dilaudid worked. I was comfortable after the second surgery. I didn't feel much or any pain. I still didn't feel "high". I had no delusions of godhood. I didn't feel sheer bliss. I was happy that I wasn't in pain, but that is not the same thing as euphoria and sheer bliss.

The surgical nurse monitored my pulse and breathing very closely after shooting me with two doses of Dilaudid. She had to make sure my respiration and heart rate weren't suppressed. There was no problem. My heart rate was between 65-68. My O2 saturation was at 97%. I was breathing fine.

This is another example of narcotic resistance for you. A resistant patient can take a double shot of Dilaudid, not get high, and not experience suppressed heart rate or respiration. If Marlin Perkins of The Wild Kingdom shot me with one of his famous narcotic tranquilizer darts, it might not work on me.

The Doc prescribed Norco for me the second time around. This is also hydrocodone and acetaminophen, however, the fuel mixture is different. Vicodin is 5mg hydrocodone and 500mg of acetaminophen. Norco is 10mg of hydrocodone and 325mg of acetaminophen. It did work better. I still experienced some pain, but not much. I was comfortable.

Incidentally, both times I stopped taking them cold-turkey. I didn't like feeling the pain again, but there were no flu-like symptoms. About two weeks after quitting the Norco, I caught a cold, but that was a fully-authentic cold. It was mostly about coughing and snot running out of my nose. This was not a case of withdrawal symptoms.

One of the advantages of being narcotic resistant is that I will probably never know the agony of withdrawal symptoms others suffer. My body doesn't like the stuff the way yours does. 97% of the people are like you. Only about 3% of the people are like me. I am a member of tiny minority.

With all that in the rear-view mirror, you can understand why Vicodin addiction is a mystery to me. I don't like the shit at all. Acetaminophen is worthless crap that hurts my liver. I don't want 500mg of that. 5mg of Hydrocodone doesn't come close to getting the job done. If a doctor were going to write me a prescription for Vicodin to control the pain of my arthritis, I might just say "thanks but no thanks, can you prescribe something else for me?"

Ask for Vicoprofen by name. 7.5mg of hydrocodone and 200mg of ibuprofen. I think 2 of those will produce the perfect analgesic effect.

With that said, I would like to say a word or two again those who recommend an FDA ban on Vicodin. The dirty little secret that the medical profession keeps in the closet is that there is only one way to control pain: block the Mu receptors on your nerves.

Despite billions of dollars in research thrown at the problem, we still have one and exactly one class of drugs that block Mu receptors. That is the opiates, or narcotics. Both terms refer to the same thing. These are chemicals that come from poppies, although a couple of patents have been granted to firms that can synthesize these agents from raw crude oil. (!!!)

This is where I have bitch-slap Mr. Matthew Herper of Forbes magazine. He recently suggested that Bextra (a chemical cousin of Vioxx) should be the FDA recommended replacement for Vicodin.

Bah! What drivel! What ignorance! He's obviousness never had arthritis.

Bextra is an NSAID. It is a Non-Steroidal Anti-Inflammatory Drug. There are many NSAIDS. Aspirin, acetaminophen, ibuprofen, naproxen sodium, and other drugs are members of the NSAID class. NSAIDs work by blocking two enzymes COX-1 and COX-2 which form prostaglandins. Prostaglandins are hormonal chemical messengers often responsible for fever and swelling.

Bextra is a so-called COX-2 inhibitor. This means it works by blocking COX-2, but not COX-1. In stark contrast, you plain old aspirin and acetaminophen block both of them. Is there any advantage in blocking COX-2 but leaving COX-1 alone?

Once upon a time, the theory said there would be. However, life is a beautiful theory ruined by an ugly fact. Years of use say there is no advantage. There may be serious disadvantages, like greatly increased risk of heart attack and stroke. Dr. Bachner will not prescribe these drugs. He doesn't believe in them. He thinks ibuprofen works best. So do I.

It is better to block COX-1 and COX-2. We should remember that common aspirin reduces the risk of heart attack and stroke. It's good for you.

EVEN IF COX-2 inhibitors like Bextra worked better than aspirin, which is not true, Bextra still does nothing to replace the Mu-blocking power of Hydrocodone. COX-2 inhibitors don't block the Mu receptors as narcotics do. If you don't block the Mu receptors, you don't kill pain. Ergo sum, Bextra can never replace the role Hydrocodone plays.

You might put hydrocodone together with Bextra, but I would rather not. Give me Vicoprofen instead, if I have to have something.

The Percocet Theory

This is going to be one of those days when I am glad that few people read my blog. I am going to do some fairly heavy speculating, but it is all coherent speculations, and not without foundations in medical fact.

I am going to tell you precisely what I was thinking as Jimmy Clausen slid down the board for 1.5 rounds. As we now know, he went dead-middle of the 1st round: Pick 48. Why?

I participate in a number of social networks related to sports. Some of them are more cordial and formal than others. Some are downright nasty, with high school and college kids throwing hand grenades at each other. Explosive allegations were made against Clausen one of the 'hand grenade' boards. Specifically, several guys who claimed to be from Notre Dame, and who claimed to have had negative run-ins with Clausen, declared that he was a Percocet freak.

They usually brought this up whenever Notre Dame hommers praised Clausen for playing injured all season long through his Junior year.

The allegations were clear: A Narcotic painkiller known for being addictive and having negative psychological side effects was responsible for Clausen's ability to practice and play with two torn ligaments in his big toe. The negative side-effects of Oxycodon, the synthetic narcotic in Percocet, are the reason he is considered cocky, pompus, arrogant, and a bad teammate.

I brushed it off, at first, disregarding the claim as a low-blow. I presumed they had an ax to grind with him. Perhaps Clausen got the girl at the party, and these guys were pissed off and jealous.

Well, I did a bit of investigation, and what I found out tweaked my curiosity. Clausen claims that his doctors prescribed Torodol for him. He claimed he had to take a Torodol pill each day before practice just to be able to practice. If so he would be dead or in the hospital right now, recovering from a sleeve gastrectomy and the shortening of his intestines.

Also, it would not have killed the pain in his toe.

I know a little something about Torodol. My doctor prescribed it for me twice. Torodol, better known as Ketorolac, is an extremely powerful NSAID. It is a non-steroidal anti-inflammatory agent. Consider it super-Naproxen. It has great power to reduce inflammation, and very limited ability to kill pain.

It also rots the stomach lining and eats your intestines. My two bottles of Torodol came with stern written warnings from the doctor, the pharmacist, and the pamphlet not to stay on the drug for more than 5 days at a time. They warned of increasing intestinal upset after use of the drug. The warnings were true. I got nauseated around day 3. I started suffering heart burn continuously. I stopped taking it early.

This was not an allergic reaction. This was the expected side-effect of the drug.

I knew Clausen's claim was bullshit immediately. Further, I knew that orthopedic surgeons don't prescribe Torodol without also prescribing a narcotic pain killer to go with it. Torodol doesn't really kill pain. The dirty little secret that the medical establishment keeps in the closet is that only narcotics kill pain. Only the stuff that grows in Poppies can stop your pain receptors from firing signals to the brain.

My doctor prescribed Vicodin first, and when that didn't work, he upped it to Norco. I learned all about painkillers at this time in my life. Two knee surgeries will do that to you.

Vicodin and Norco are based on the same chemical agents, and they are different from Percocet. Vicodin and Norco are based on Hydrocodone. This is the least addictive narcotic pain killer currently known to medicine, but it is still addictive. Brett Favre had a problem with this agent. Hydrocodone is rated at half the power of Morphine, unit for unit.

Percocet is based on Oxycodone. It is a lot more addictive that Hydrocodone. Many people have addiction problems with Oxycodone. It is called 'hillbilly heroin' because of its tremendous popularity in the Appalachian mountain region. There were alegations that Mike Vick had a problem with Oxycodone before he was shipped off to Fort Leavenworth Kansas. Oxycodone is also rated at half the power of Morphine, unit for unit.

Vicodin, Norco & Percocet all have varying amounts of Paracetamol in them, but that is of little importance.

The important difference between Oxycodone and Hydrocodone is this: More thebaine vs. less. Thebaine is one of three primary chemicals found in Opium Poppies that are useful to Orthopedic surgeons. The others are Morphine and Codeine. Unlike Morphine and Codeine, doctors never prescribe thebaine directly for patients. However, it is on the controlled substance list of the FDA.

Why is thebaine controlled? Because thebaine is chemically similar to Morphine and Codeine, and it can be chemically synthesized into all manner of narcotics, if you know how. One of those synthetic narcotics is Oxycodone. Some thebaine is also required to manufacture Hydrocodone, but not nearly as much.

Thebaine is a curious chemical. It is a powerful stimulant. It will cause strychnine-like convulsions at higher doses. This is the only member of the opiate family that is s stimulant. All the rest are depressants, and mildly hypnotic. All other narcotics suppress your cardiovascular system, and they make your drowsy. Thebaine does not. Neither does Oxycodone.

If you are an athlete or mind-worker in pain, Hydrocodone may kill the pain, but it messes up your work schedule. Oxycodone does not. Rather, it kills the pain and kick-starts your ass at the same time. You can understand why football players would consider it fantastic.

Like all narcotics, Oxycodone tweaks the Mu receptors on your neurons... unless you are narcotic resistant like me. I have the rare mutant Mu-Beta receptors. Tweaking the standard Mu receptors blocks pain and triggers a big release of Serotonin from the brain. That makes you feel fantastic; on-top of the world. The serotonin, the pain-free state, and the stimulant makes you want to go out and do battle.

This is why it is frequently prescribed for those dying of cancer. It helps them avoid becoming bed-ridden shut-ins for as long as possible.

I myself have never experienced the Serotonin rush from narcotics. It's all my doctors can do to keep the pain down. I am a narcotic resistant guy by genetic endowment. Only 3% of the world is like me, though. Almost everybody I know, reports feeling absolutely incredible after taking Norco. I just transition from a state of greater pain to lesser pain, and that is all. That is good, but it is not pure bliss. Others experience pure bliss.

97% of human beings feel super-human, even god-like if they take enough of it. Delusions of godhood and extreme cockiness are side-effects of a good dose of Oxycodone. Rush Limbaugh manifested extreme cockiness before he went away for rehab. Same thing was true for Mike Vick.

That brings us back to Clausen.

Suppose you have a turf toe with a couple of torn tendons. You can't take Torodol for long. It will rot your intestines, and it won't really kill the pain either. A friendly and helpful Notre Dame doctor gives you a prescription for Percocet, knowing it won't hurt, but indeed help your performance. It's good. It works. You like it. You can practice and play like a million bucks.

You have to come out of it sooner or later. It's hard, but you do it.

Unfortunately, the NFL has it's own version of the Black Water Security consultants. They can find out anything. They find out about the Percocet from websites where kids throw grenades. They investigate. They find out it's true. The NFL knows you used Percocet for an entire season. They know that would explain the cocky arrogance. This information is released to the 32 NFL teams under an NDA.

Nobody wants a drug problem at the Quarterback position. Just the off-chance that you may have a tendency to like Oxycodone is cause for concern.

Suppose, in the first place, that the candidate is not really as good as Mel Kiper Jr says he is. Suppose he might come bundled with the Oxycodone baggage.

That's enough for mildly interested parties to become totally hands-off. I think that is what happened during the 2010 draft.

First blog entry after knee surgery

So, this is my first blog entry after having had knee surgery on the 8th of January. The surgery seems to have gone pretty well. Despite the fact that the surgeon made three incisions in my left knee (as opposed to two in my right) this has been a far less painful process than my last surgery.

I really could put weight on the left knee almost immediately after surgery. It was a bit tender on day two, but it was solid afterward. I could straighten it and bend it a bit immediatly without pain. None of this was the case with the right knee. I still have some ugly inflamation above the left knee, and I did bleed a bit (in the shower) from my stiches there last night. However, all things considered, this left knee surgery has been much easier than the right.

I was pretty grogged coming out of the surgery this time. Dr. Bachner came over to me and said "The surgery was successful. We found a lot and lots of things that could make you hurt." It sounded like he did a lot of work. I thanked him for his efforts. That is all I remember.

I do remember that it was approximately 11:30am when they wheeled me into the surgery room. There were atomic clocks posted on the wall all over the joint. It was 1:30 PM when they wheeled me into the recovery room. That means I was in surgery for almost 2 hours. Last time it was just 1 hour. Once again, it sounds like a lot more work was done.

The greater grog and the easier ride may have to do with the pain killers they gave me. I felt very little pain coming out out of the Propofol. Last time the right knee burned and throbbed and ached immediately. The abscense of pain this time may have had something to do with the local painkiller they shot into my left knee. It also had something to do with the double shot of Dolantin the surgical nurse shot into my IV bag. {By that two distinct injections into the bag.} It may have been related to the injection of Torodol they gave me. It could also have something to do with the Vocodine chaser she gave me. It may also have something to with the Norco + Torodol pills the doc prescribed for me to take later on.

Norco is literally twice as powerful as Vicodin. 10mg of Hydrocodone vs 5mg. Torodol is a hyper-strength NSAID that has to be taken with a meal because it can really upset the tummy. It is the very best thing for killing inflamation, but you cannot take it for longer than 5 days.

They obviously weren't taking any chances on me writhing in agony after the surgery. Once again, it sounds like the Doc did a lot of work on my left knee. I greatly appreciate the fact that I was able to sleep well all week. This has helped me to recover faster.

The post-surgery rehab experience

So rehab is now underway. I went to my first rehab session on Thursday. The night before, I found the courage to get up on the ROM machine and do the lower body workout. Much to my shock and joy, I performed extremely well. The knee felt as good or better than it did before the surgery. My performance was strong. I didn't try to push it hard, but the results were good. I did 1 minute, 2 minutes and 1 minute. The resistance was my normal 220 pounds.

Words cannot express how relieved I was when the workout was over, and the knee didn't turn into a radio active H-bomb of pain. I was so stoked up that I got up on the Elliptical and did 5 minutes. I found myself pressing much harder with the right, even leading with my right leg. This is something I have never done before... at least not since the day I bought the machine some 15 months ago. This suggests that the knee is coming back, and it will be much better than it was before my last injury. That is exciting.

Not surprisingly, I went to my first rehab session with a little inflammation. This may have had something to do with the fact that I had taken no pain killers or anti-inflammatories all day. My first rehab session yielded good results. The PT was surprised that I showed 105 degrees of flexibility in my right knee. He was expecting 90. My left only shows 117. I am within 12 degrees of my other 'normal' knee. That left knee has seen plenty of damage also. It may be the next contestant for Arthroscopic surgery.

The exercises I did were a doodle. I doubt they helped. However, the PTs performed Ultra Sound and Electro-stim work on me. This was very good. I believe this was the primary factor that led to my good results. This morning I was walking almost completely normally. I was able to stand up a bit quicker than before, and move down a flight of stairs more rapidly that any time after the surgery. Standing up from a seated position seems to be the most persistent source of pain. I look forward to the days when that will end.

Speaking of pain, I have become something of an authority on painkillers since my surgery. I wanted to know and understand every agent they gave me, from liquid injectable Demerol &Toradol, to Ketorolac, to Hydrocodone + Acetaminophen.

What can I tell you about these things?

1. Demerol works like hell. Kills pain dead
2. Toradol works when injected, but only to reduce inflammation. I don't think it kills pain well at all.
3. Ketorolac sucks shit. It did nothing but upset my stomach. I have most of the prescription left. I won't use it. It is good for nothing.
4. Acetaminophen by itself is for the birds. It is better than Toradol insofar as it has fewer side effects, but it still sucks. I get very little relief from Acetaminophen.
5. When combined with Hydrocode, Acetaminophen works fairly well. However, I did not find this combo to be particularly powerful. It took the pain down about 50%, but that still left me with 50% of the pain. I still suffered a lot of pain, despite this stuff. I gutted it out because I have balls. Call me Emmit jr.

If the Doc does my left knee, I am going to ask him to prescribe Combunox for me. I have spoken at length with several people who have had these surgeries, including one dude at rehab. To the last man, they all say Combunox rocks. It is the best painkiller money can buy.

So what is Combunox? It is the dreaded oxycodone + Ibuprofen. The difference between oxycodone and hydrocodone is obviously hydrogen vs oxygen. Oxygen works better. I don't know what you think, but I think Ibuprofen absolutely kills acetaminaphen in all phases of the game. For these reasons I suspect Combunox is the way to go next time.