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Tuesday, November 7, 2017

In the Hands of Experts - A Paramedic's Journey To the Other Side

It's been nine months, since I had my spinal fusion surgery.
This procedure is not designed for pain management, it is designed for adding stability to an unstable spine. The reason I had it, is because:

  • My surgeon believed that all else had failed
  • I was still living with unbearable, daily pain, despite high doses of opioids for over two years
  • My surgeon believed if he were to add stability to the area, it would be reasonable to expect there might be subsequent pain relief. 
I agreed.

Since February, I've been through months of physical therapy. I returned to my teaching job after 12 weeks and my EMS job after seven, long months. I've lost over thirty pounds and have happily had to purchase the first smaller sized clothing since I was a boy. 

The article below began as a Facebook post on February 17, 2017. I have since modified it slightly to add more specific detail and correct any errors. This is an account of what I went through immediately after my surgery as a patient at Meadowlands Hospital Medical Center, in Secaucus, NJ. When my surgeon suggested this facility, I immediately balked, as I've had my fair share of negative experiences with their ER during years of EMS work in Hudson County. Then I reasoned, "it's not the ER, and it's only a surgical procedure." The surgeons need a place with more resources than a surgi-center, "how bad could it be?" -- I found out. Thank you for reading.

Feb. 17, 2017 - FaceBook

I have some things on my mind that I need to let out so I can move on with my life.


Last week I finally had the back surgery I was waiting for, for the better part of a year. My first surgery (a decompressive laminectomy) failed. My surgeon, who I trusted, had privileges at Meadowlands Hospital Medical Center, a place I never trusted before, and never will again as a result of my post-op nightmare there.

Hill Rom Adjustable Bed
Following the surgery, I was transferred back to my bed and moved to the recovery room. Hours later when I awoke, I was in agonizing pain... pain like I had never encountered in my life! I complained repeatedly that I felt like "there was metal rubbing against my back." They thought I was speaking in metaphors, about the new metal hardware I now had in my back. I was not. I felt metal scraping along my freshly closed surgical site, which lined up with the hinge in the bed where the head articulates up from a supine position.

The beds they use are the Hill Rom adjustable beds, like many other hospitals. These are metal frame beds that make several adjustments and some models have special mattresses that, once connected to a power source, inflate with air (when they're working).

I writhed about and attempted to shift my weight. The more I moved, the more it hurt; the more I stayed the more it hurt. I couldn't take it. I told my family, who in turn told the nurses. We held the false belief that someone would raise a flag or say, maybe even do something. We even told the people in the ICU, where I was headed after my stay in recovery. My cries for help fell upon deaf ears.

They moved me into the ICU around midnight. We were expecting a blizzard that night so there was a buzz of anticipation in the air. Off-duty personnel came in droves to sleep at the hospital, to avoid having to drive on the snow-covered roads. This way, they would be ready for duty when their shifts began in the morning. That buzz turned into very noisy conversations, not controlled by any ICU personnel. Rest became an elusive impossibility. All the while, my back is screaming for relief and I... was unable to move in any direction; trapped in a painful nightmare.


My ICU nurse was a pleasant, but seemingly overwhelmed young lady who was forthright, and admitted that while she is not a "new nurse," it is her very first day in this hospital, in this ICU, and... she has had no orientation and there was no supervisor in sight. Can you tell where this is headed?

I inquired about how we were going to control my pain. Based on my previous surgery (just a year earlier), that resulted in a subsequent hospital admission at Newark Beth Israel Medical Center (NBI), I shared how they managed my pain (successfully) there.

At NBI, they assigned a pain mgmt. specialist that spent several days with me. He tried various configurations, before he got me -- not "well" -- but less miserable. The mix included Dilaudid, Oxycodone, Fentanyl and Flexeril. MMC's plan was to use Oxycodone alone... and at the same dose I've been using at home -- for "breakthrough pain." After a lot of complaining and explaining that I am 10/10, and in excruciating pain, they allowed me 2 mg of IV Dilaudid. I felt like a junkie, a seeker, like the countless seekers who I've had in my ambulances over the years. You could see the doctor's eyes roll when I asked for the drugs by name and dose (usual tell-tale signs of the seeker).

The night was the longest of my life. Every minute felt like an hour. I called home almost hourly - broken - in tears.

So, why was I in ICU in the first place I asked? They said they needed to monitor my vital signs, and particularly look for signs of narcotic induced hypoventilation. Now we're in my house! This is one of my specialties! I craned my neck and searched for my end-tidal CO2 monitoring with waveform (snort) yeah, no. There was nothing. I imagined this was what Joan Rivers might have felt like, except she didn't know she was supposed to have her CO2 monitored (she might have still been with us if they did).

Tick tock, tick tock, the moments dragged ever-so-slowly. The noisy conversations went on and directly across from me was a man on a ventilator, laying on his back with his head facing his right shoulder. In an attempt to stay calm, I would focus on the sound of his ventilator, and watch his readings as his Diprovan slowly dripped, punctuating the passage of time. 

Daybreak! I now saw the sun over my shoulder. It illuminated my vented friend across the way. Aside from the occasional suctioning of his secretions, he lay motionless the entire night. Beside him hung a sign that reminded ICU personnel to turn him occasionally to prevent bed sores etc..

I was famished and COULD NOT wait for breakfast. I had been NPO (nothing by mouth) for 36 hours now and only had some clear broth the night before. I asked when the food would arrive; "eight thirty Mr. Velasquez." I wanted to die as it was over two hours away, and my back was still incredibly sore, not surgical site sore, the skin and tissue that makes contact with the stretcher - that kind of sore.

To add insult to injury, I began spiking fevers through the night. I would begin shivering and asking for blankets, nod off for a few then wake up again, covered in sweat. My gown, sheets, blankets, everything was soaked... and so they remained.

I finally convinced the doctor to grant me larger doses of Dilaudid but needed to make the case for myself. I explained that I'm a 6 foot tall, one hundred and fifty kilo male who has been on opiates for the better part of two years. I'm post-op and writhing about in pain. 4 mg was his generous response, alternating with a 30% greater dose of oxy than what I take at home. Still I agonized.

Eight thirty arrived and they placed a tray with a big opaque dome over it. Like Pavlov's dogs, I salivated at the thought of some f'ing food! Voila!! More broth and jello. I almost hurled the pan across the room! A sympathetic nurse heard me out and ordered another tray of some solid food. At this point, I didn't know what to cry harder about.

I continued to complain about my bed for hours and finally that afternoon, someone asked the question; "see if it's inflated." It was not. For over twenty-four hours now, I had been laying on a flat piece of metal with a deflated mattress, where the bunched up plastic from the mattress scraped across my surgical site day - and night - and day. They finally got some people together to move me onto a functioning bed beside me. My vented friend across the way lay motionless. I imagined he appeared shocked about what he was witnessing. Drip... drip... drip... his Diprovan dripped on.

Some doctor comes in and starts making a big deal about my Dilaudid dose. "That's a really big dose! Like I've never seen that much Dilaudid given to anyone!" Excitedly he told the flock of med-students behind him; "That dose would literally kill most of you!" (I'm pretty sure that's not true doc. Either way, this is not comfortable conversation for you to carry on with your little doclings. Get lost!). The doctor began to lecture me about a condition called OIH (opioid induced hyperalgesia). Scholastically, he reasoned that he thought I was having a paradoxical response, where I actually feel more/or different pain than I originally felt because of my prolonged exposure to opioids. I wanted to throat-punch him and cause intense pain on the young scholar. Why could I not just get the same level of competence I got at NBI? Why was I trapped in this f'ing nightmare, unable to move, unable to defend myself? I had never felt so vulnerable before.

As the hours went on they never brought me my pain meds on a schedule. They forced me to wait until I was in tears and could bear no more. Only then, they'd disappear for a long period of time, and finally return with what I needed. Sweating, shivering, immobile I laid. Across from me, my vented friend laid, equally immobile, but fortunately for him, unaware of the care he wasn't getting. Drip... drip... drip... went the Diprovan.

My rookie nurse from day one returned.. She apologized about the food, the bed, the pain meds or lack thereof. It seemed that was all she could do was to apologize.

Respiratory came by. Now he and I could jam and talk forever. He immediately engaged me and talked about ETCO2 monitoring, its uses and benefits. He understood that as a paramedic, I used ETCO2 a lot, and at a high level. I asked him if anyone here on the floor had anything beyond the most basic understanding, something other than what a normal range is... he laughed. He placed a cannula on me that could deliver oxygen and monitor my carbon dioxide. Him I liked.


At one point my ICU nurse came by, looked at the monitor over my head and exclaimed; "ohhh, we have to get your sats up!" Sharply I replied "That's my end tidal." "Yeah, I know but you're not satting well." I began to wonder if I'd survive a fall from the ICU's window into the snow below.

Sometime in the afternoon, a robust Italian looking doctor, who appeared to enjoy the sound of his own voice, came in, trailed by a gaggle of impressionable doclings in his wake. "This guy can go. That bed can go, and this one here, he doesn't need to be in the ICU! Let's get these all discharged" he said with an air of equal parts condescension and contempt.

Dr. Drive-By did not introduce himself, did not know me, speak to me, or acknowledge that I was a human being. I felt like a piece of furniture in a house with a tag on my forehead for the movers to make sure they move me. He wanted me to be moved to a regular floor.

My rookie nurse did what she could to stall this. She knew according to their policy, IV Dilaudid can only be given by an ICU nurse on their floor. Anywhere else in the hospital, it's given either IM or PO and with a 2mg max dose. She advocated for me and delayed my transfer.

At some point that evening, another nurse with a European accent took over my "care." My pain, again, was through the roof. I finally got her scattered attention and I asked for my pain Rx. She spoke like Madam Yes of the Flintstones; "Next time do not wait until you are this bad before request pain medication!"

My vented friend of almost 24 hours now, stood in his bed, shocked at the display of such horrible care. I could swear I almost saw him move a little. Drip... drip... drip went the Diprovan.


Finally it appeared my new room was ready. I wanted to talk to someone about my pain management, as I was not being forced into a 50% reduction in my Dilaudid and changing the route because of this ridiculous policy! Yes, I know, we're worried about respiratory depression on a floor where one doesn't have that "one to one expert care" that I was getting in the ICU! You have got to be kidding me, I thought.

So they roll me about twenty feet down the hall to my new room. "At least it's a private room" I thought. Maybe I can actually get some rest not listening to Madam Yes and the other chatter boxes in the ICU.

I'm greeted by a very friendly nurse and her aide. They explain everything to me and I wanted to have a discussion about how they're going to manage my pain. 20 minutes ago, Madam Yes assured me, and gave report to this new crew, that I would be getting 2mg of IM Dilaudid. Yeah, no. Somehow there was a vacuum in that 20 feet of distance we traveled, and there was no mention of Dilaudid there at all! I hit the ceiling! How did I KNOW they were going to f' this up too; and who do I talk to, to unfuck this!?

The new nurse tries to calm me and apologizes, again and again, that she will do everything she can to "manage [my] pain." She runs off and calls the hospitalist, another drive-by that knows NOTHING about me, my history, my body habitus, what surgery I just had. She returns with... wait for it... 2mg of Morphine! "This should take your pain away Mr. Velasquez!"

No! No!! No!!! I want to talk to someone! Who just arbitrarily DC'd (discontinued) my Dilaudid without ever conferring with the fucking patient!!??? Who's the amateur here? 

"Well Mr. Velasquez, the hospitalist makes that decision." 
"Then get him here!" 
"We can't, we can only call him for STAT orders for meds and he will not give an order for Dilaudid, after just giving Morphine. We'll have to arrange a pain management consult in the morning. But don't worry, you can have your Oxycodone in four hours and every four hours after that. Here is your call bell if you need us. We're very sorry."

As the night progressed, again came the fevers, the sweating and the soaking of sheets. Whenever I had to pee, it was a shit show as I'd push the call bell and eventually 1 five-foot tall female would come to my room. Then she'd have to call for the tech who took longer. All I wanted to do was to sit up and use the urinal, but I couldn't. A searing pain shot across my lower back like I had just been shot. Finally, they got me up and I could relieve myself. They disappeared and back onto my soaking sheets I'd lay. I prayed to my God for forgiveness for anything I had done... or was about to do. I just wanted to get back to my MICU, back to my team of heroes and colleagues, roaming the streets and providing competent, compassionate care again. It seemed so far away. I exchanged views from my vented friend's drip chamber to slowly falling snow flakes out my window.

The next morning no one answered my call bell. My urinal stood full and unaddressed, my sheets still wet and bunched up beneath me causing more pain. A cleaning person came in and said she'd be in to clean my room shortly. Two hours passed and she was nowhere to be found. Desperate and needing to pee, I wrestled with my side rails, grunting, struggling, sliding toward the edge of the bed. I thought I was going to pee myself  at one point, as I desperately searched for something to urinate in. I found the basin with my personal care items and threw them across the bed. I just barely was able to urinate into the basin and could only leave it on my food tray. I really needed someone to come help me. No one came.

Later in the afternoon, I lodged the mother of all complaints with the nursing supervisor. My room reeked of urine, my dressings were falling off my diaphoretic body. My nerves, frayed from the experience. She was sympathetic and agreed with my assessment. She barked at her nurses and other personnel. She made a phone call and got their stupid f'ing policy overridden and got me an IV dose of Dilaudid which immediately quelled my pain. I couldn't wait to get the hell out of that hell-hole. Tick tock... tick tock... tick tock...


I have so many friends out there in the critical care community, I only hope that you never treat your patients the way I was treated. My heart really goes out to those that don't know anything about medicine, who can't file a complaint because they wouldn't even know what to say or how. People like my vented friend who, I'll bet, a week later is still in the exact same position just waiting to be a lovely host to a pneumonia or worse.
#happytobehome #MMC #meadowlandshospitalmedicalcenter #hospitals #njhospitals #horriblecare #striveforfive

November 2017 

Months have passed. My pain is still a daily issue, but I've managed to get back to the MICU, back to my streets. The surgeon's next move is to put a pain stimulator in my spine permanently. I've already had a 5-day trial with it and it had some positive effect. I'm so desperate to make this go away, I feel like I'll try anything. So, we're scheduling a date in the near future to put the device in.

My surgeon's office called this week and asked if I'd be okay going to Meadowland's Hospital Medical Center in Secaucus.