Tuesday, June 25, 2013

Arthoscopy 15 days later

Last week
There is a vast improvement, so hopefully this trend continues. The PT sessions work wonders really... So I must keep conscientious on my PT exercises. 

The only trouble I have this week is still walking up and down the stairs.

Monday, June 24, 2013

Health Insurance

This is my first time using services from US medical insurance. I have no idea that you have to call to authorize a referral before it can be approved.

*Cross my fingers... I hope I don't get charged more than I am supposed to ... Aaaargh.

Reading this, just exacerbated my worries.... I don't have that amount of money...

Sunday, June 23, 2013

Haze Hype!

Singapore PSI breached the 400 mark!

Gosh... It's as if the climate is not warm enough. Now there are tons of particles up in the air containing even more of that heat and humidity. Plus, there is the respiratory problems that the particulates and irritants can cause.

I do my friends and family are drinking lots of water and taking measures to take care of themselves as best as they can.

I read that the respirators can be kept for about 3 years, so I intend to buy some to bring back for my folks and my gf+her folks for the next 3 years at least. In case, things get depleted next year again, they still have some.

Anyway, found this site showing some of the uses of the different kinds of respirators:

It seems that they are ordered by their increasing capabilities.

Hopefully, people in Singapore are seeing clear skies and breathing better soon. Hang in there people!

Setting up the Apache server on Linux

A malfunction of the website of a tool that we developed inspired me to write this post to whomever may need to do this. This entry is not meant to be exhaustive but it's more of a practical guide to setting up the Apache when I was making the webpage.

1) set up the VM with the system admin. If you have VirtualBox before, this works somewhat like it.
-- be sure to ask for root access.

2) all website content is presented in /var/www/html/
-- put soft links into this folder to direct to other folders if required

3) to make content public on the WWW, we need the switch on the Apache HTTP server. Imagine the Apache as a middle man between your console and the WWW, it 'advertises' your content on the WWW.

Use the following command:
$sudo \/sbin\/service httpd start

Replace 'start' with 'restart' to reboot and 'stop' to switch off.
We should see something like that to know that it is working (or not):
Starting httpd: httpd: Could not reliably determine the server's fully qualified domain name, using server.name.123 for ServerName
                                     [  OK  ]

[sudo] password for user123: 
Reloading httpd:                     [  OK  ]

4) Check on the WWW to see if the website is up. If it's not, debug using the Apache log file.
$less /var/log/httpd/error_log

This log file will tell you what is wrong and the IP of the client that was trying to access the site.

5) When you add files from your home directory, sometimes it doesn't appear on the website and the log file says that it couldn't access it. 

First, make sure you have cleared your cache to see for sure you are looking at a refreshed page.
Second, go to your VM and check the permission of the file that you are looking at:

$ ls -alZ
-- this will help you check the permission and ownership of the files. (1) Apache should be able to read all of them; (2) configuration/permission should be: unconfined_u:object_r:httpd_sys_content_t:s0 not unconfined_u:object_r:user_home_t:s0

$ sudo chown apache:apache file.txt
-- solves (1)
$ sudo restorecon -r file.txt
-- solves (2)

6) Add this line to ensure that the HTTP server reboots together if the VM restarts
$ chkconfig httpd on

Things should be in order now.

Arthroscopy Days after

After Day 10, I can walk on 2 finally. After a mere session of physical therapy, I could feel a huge difference - I think the muscles and bones needed a little more than nudging perhaps to get them back to normal.

So right now, the routine is basically ice and physical therapy exercises at home and to attend the sessions at the clinic. 

I could feel the swelling subsiding and my knee bones showing, albeit still very slowly. It's almost 2 weeks from the surgery but I still cannot walk normally yet. There is still fluids pressing around my patella. The doc had said that lateral meniscus tear is more difficult to recover than medial meniscus, so I would have to be patient. 

The key is really to keep cool and distract myself and not try to hasten the recovery by doing something stupid. I would probably have to faithfully keep doing my PT and let nature takes its due course... 

Saturday, June 22, 2013

Arthroscopy Days 4 - 8

Ice, ice, ice, ice. Keep icing. As long as there is swelling never stop icing.

Cover knee with polystyrene bag when showering.

Walk with crutches.

I removed my bandage on Day 7. See the 2 incision points and my swollen knee:
See the knee cap on the right side against the swollen knee on the left.
2 incision points
On Day 8, I went for my first post-op. The doctor said that I am healing well and had me walk without crutches and straighten my knee. When I straightened, some blood oozed out of one of the incision points. But doc says it's fine. He recommended that I try to lay off crutches to walk around the house more often - as often as my pain level allows. At this stage, without crutches, I realized I could walk, albeit slowly and limping. He also wanted me to get onto physical therapy ASAP. So I called up the physical therapy at the Health plan for an appointment the day after tomorrow.

Tuesday, June 18, 2013

Arthroscopy Day 2 and 3 - Some survivor tips for living alone

Living alone can be a real bitch when you are on crutches.

Days 1, 2 and 3 are arguably the most crucial to the recovery of the knee. The ICE - ice, compress, and elevate - 30min/30min will reduce swelling and the flexing of the foot will improve blood circulation. You don't want to be moving around too much but the occasional call to nature and for meals, will help against blood clots.

But these are all nice if you have somebody to tend to you. Staying alone prevents you from such a luxury, and you want to be really cautious about the knee.

**WARNING: you are going to need your good knee very much during these 2 days. I would recommend training up a bit LOLX

I would recommend staying off showers for Days 2 and 3, since you are staying at home and it really doesn't stink up very much, especially if you have done so on Day 1 and your house is properly ventilated. I chose this easiest option.

Alternatively, you have several options:
1) Cleanse with wet cloth + shampoo hair using sink -- cover bad knee with plastic/polystyrene bag taped with masking tape
2) Dry bath, what we do when we are out in the jungle in military, where we powder ourselves with talcum powder/'snake' powder

Get a chair in your toilet before the op. I am assuming your toilet is not wheelchair-friendly, so it wouldn't have those bars for you to hold. The chair acts as one of those for additional support to get up and down the toilet bowl. Remember, your crutches always on your bad side to support your bad side.

Before this week, I would have stocked up on groceries for 2 weeks at least. Have some prepared food available in the freezer too.

The main difficulty comes with cooking the food and washing up. In both cases, you need to be carrying things around. But this time, you can only do it ONE AT A TIME. So it requires A LOT of back and forth (especially if you forget something).... But the important thing is to maintain your composure and tell yourself to relax and that this is only temporary.

You would need to have a steady arm the side of your bad knee. As 'luck' as it, I am a left-hander (my left knee is injured). A very simple trick I do as you are moving around on crutches with ONLY A SINGLE DISH in your hand a time please -
1) hold your crutch of the good side as per normal, but the one on the bad bad side, squeeze your crutch under your armpit while you hold the dish.
2) Then to bring the crutch forward, lean on your good side a little, simultaneously rotate your shoulder and swing it forward a small distance, not very wide at all. Try with short distances to gauge how much you need to swing.
3) Next, lean on that swung crutch. Coordinate to bring your bad foot with your right crutch forward together at the same time.

This takes some practice, but it worked quite well for me and got really easy with more practice.

If you have prepared food, make sure to use a plate to hold your microwaved food for easy handling. My other small trick is to get a rice cooker. Get one of those you can steam extra food on top. Put in enough rice for 2 meals, lunch and dinner. Dump in the meat and vegetables on top to steam with the rice. After 1 hour, you would get entire meals very easily.

**You will still have to be extremely slow and extremely cautious. Look out for obstacles and try to clear them before your op, in your kitchen. I took an hour or more for each meal. 'Slow and steady' is the mantra.

I want to take this opportunity to thank the Thai cart couple, P and A, for driving all the way to deliver the food I ordered!!! They are such a wonderfully sweet couple!! Always willing to lend a hand =)



You will get frustrated on how slow you have become and vexed with having to do things so many times. When that happens, I always stop and then reflect that this is only temporary and that I should consider if you have more haste, you would go with less speed. Frustration leads to more mistakes and accidents, e.g. breaking plates, which only serve to make matters worse.

So always maintain a calm composure as you move about your meals especially. Whistle if you must or sing a bit. This is only temporary, but if you hurt your injured knee under such vulnerable circumstances, it will be permanent. So 'more speed, less haste'.

I never realized how much depend on 2 knees until you lose one. I relied so much on my right knee, I could swear it grew much more muscular after this whole ordeal. But it is also with such thoughts that you will be more mindful to not take things for granted.

Arthroscopy Day 1 - SURVIVOR tips for staying alone

June 10th 2013

I picked up my painkillers, Percocet, days before. I live essentially by myself. So I have to reorganize my bedroom a little to make sure I have most of the necessary things at my bedside: a water flask full of water, my pain meds, my books, my readings, pencil case, a small trash bin and my laptop with power cable and iphone charger.

I took a shower in the morning before heading out. Since I reckon I won't be able to shower for the next 2 days at least, I took pains in scrubbing and cleaning things out twice and hard.

No breakfast. No water still.

LA came to pick me up at 9 in the morning. I planned to reach there way ahead of time. The surgical center is in Branford. I was expecting rush hour, but there wasn't! So we reached there way before.

After some time in the waiting room, they started prepping me for the op. I changed into surgical gown. The nurse C was extremely cordial, asking if I am cold and if I wanna watch TV. So I have blankets, even though I wasn't very cold and there was TV. Channel surfing isn't my favourite pastime but it's better than stoning. She gave me 2 pills, 1 Reglan and 1 Zantac, for the stomach, since I didn't have any food since 12 yesterday. And then she taught me how to use the crutches, which she got one pair for my height. I was then put on saline IV. C was commenting on the bruises I had from the pre-op blood-taking. Because they took twice (they forgot they had additional tests..) side by side, she said they look like a vampire bite LOLX. Haha, either it's due to the 'True Blood' and 'Twilight' frenzy or otherwise, I feel slightly amused. She could have likened that to a viper bite or dragon bite or simply a fanged bite or said nothing at all, which is probably what many nurses would have done. We and some nurses laughed and the mood lightened a lot.

Throughout the whole thing, I felt really taken care of - which is the general feeling I got out of the whole COS experience. I don't feel neglected and rushed, which I thought was a good change from public hospitals back in Singapore haha, even though I must say the nurses did their best there too. Though I could say less for the doctors...

One of the nurses came to ask me if I am allergic to pain meds and other meds. I was pleasantly surprised they asked me if I know if lesser dosage is required for me since I am an Asian. Some people might find this offensive. However, as a scientist-in-training and having my previous work being on ethnicity influences on drug effects (there is a substantial influence) and their clinical uses, I must say I am absolutely impressed.

Then Dr Diana came to mark me on my left knee with his initials 'RD'. Kind of like branding haha (too much 'Spartacus') but it's comforting to know that they take precautions to make sure they don't open up the wrong limb or the wrong person or both. I think that's what patients need from the clinicians - that sense of reassurance to entrust part of us to him, even if it's fleeting/temporary. Put also confidence and soothing words of encouragement into the mix. Oh, since I am on local anaesthesia, and I opted to watch as he does the menisectomy =) I saw a video online, but nothing really beats watching a video of your own surgery as it unfurls right there =p You can watch a sample right here and more info here.

The surgery is only about 30-minute long. The nurses in the op room were amazing! They kept me relaxed. Even though I am sedated locally, I could feel my senses dulling down a few notches... Throughout the procedure, Dr Diana walked me through what he is doing. He first made 2 incisions on the skin of my knee cap to push the instrument through. I did feel a sharp pain, maybe just before the anaethesia sets in. After I sounded out, all's good thereafter. Then the surgery proper. He pointed to the meniscus and the bones (watch the video above). He pointed to a hole that was my tear. Imagine white thin fabric against the sun, and there's a medium-sized hole in the middle. That's how I saw it. There was some snipping, and some 'vaccuming' of the debris. Then it was done. Faster than I expected, maybe because the watching took my mind off the time elapsed.

I was wheeled into the recovery room. There, I was given an energy bar and water!! I was pleasantly surprised by this gesture haha; my stomach was growling by then. I still felt light-headed. LA came in to help me remember things that the nurse was about to say. She taught crutches again, for normal walking and up and down the stairs (very important since I stay on the second floor); icing and compression devices, which they provided (pleasant surprises everywhere). I am going to list them below later if anybody might find useful.

Keep yourself hydrated all the time!! I will provide more stuff in later updates.

***A very important thing to do is to flex your foot while you are icing to increase circulation.
***Do not stay in bed all the time, walk about for meals and bathroom to increase circulation. Increasing circulation prevents blood clots (which the doc says is something people neglect)!!!

A huge shoutout and thank you so much to LA, for ever being such a great great friend for driving me there and sending me back and making sure I was properly settled in. And also helping me to remember things.



Check that crutches are of good height, just below your armpits.

Normal walking:
Since I can exert partial pressure on my 'bad' knee, and full pressure on my 'good' knee,
1) 3 things go forward together, the foot with bad knee, and the 2 crutches, then your good foot goes forward.
2) crutches are always kept on the bad side.
3) to turn around, walk in an ellipse
4) to sit down, walk to forward to the chair, gauge, turn around using (3), then inch back till your leg touches the chair, move your crutches to the bad side, hold the handle of the chair, lean on your good foot, stretch out your bad foot. Never bend the knee beyond 90 degrees.

-- good detailed video here to demo how to use the crutches.

Going up stairs:
1) crutches level with where you are standing
2) good leg up first
3) then crutches + bad foot

Going down stairs
1) crutches + bad foot down first
2) then good foot

-- good video here



I have to spend the next 48 hours icing and compressing for 30 minutes then leave off for 30 minutes then repeat. This reduces swelling.

***A very important thing to do is to flex your foot while you are icing to increase circulation.
***Do not stay in bed all the time, walk about for meals and bathroom to increase circulation. Increasing circulation prevents blood clots (which the doc says is something people neglect)!!!

I didn't know they were going to provide a compression device (the link I provide from Amazon, with the pump, comes only with one ice gel I think) and 2 ice gels. I got the one I had for my ankle and bought another one from Amazon. So I rotate between these 4, very well keeping the gels cold all the time. My ankle gel needs about 2 hours or more to be really cold (it's got a really a lot of gel in there), so I guess having 4 is good. Check how long it takes to cool them if you are buying them online.

1) I have to apply ice gel.
2) layer the compression OVER the ice gel then pump air to compress.
3) lift the knee above heart level on bed by propping up 2 or more pillows.
For 30 min.

Then fallow for 30 min before repeating.

At night, I don't follow the cycle. I put one ice gel before I sleep then I remove only when I wake up for bathroom. I will also swap out the old warm gel for a new cold gel from the freezer.

Game of thrones

Old stories are like old friends. You have to visit them from time to time.

"Brandon Stark"
G. Martin

Monday, June 17, 2013

Arthroscopy Pre-op

I think it was a novel enough experience that I should blog about it. The last time I had an operation was a surgery on my finger. And it was quite a lousy experience, considering I wanted to punch someone with my other arm. -_-|||  But that's a story for another day...

This time round, I have Dr Richard Diana from Connecticut Orthopaedic Surgery for a surgery on my left knee - a lateral meniscus tear. He is extremely patient, walked me through his diagnosis, the MRI and what he recommends I do and what he was going to do. Answered my queries and concerns about insurance coverage and risks. Wasn't pushy when I said I wanted to give it some thought, since surgery does have its risks, no matter how small the surgery is and also I had to consider other factors like family inaccessibility, staying on the second floor, my schedule etc.

 - Right knee profile -
medial is inner, lateral is outer of the knee and typically blood vessels are in the outer rim of the meniscus
(Source: http://en.wikipedia.org/wiki/File:Gray349.png)
I had my concerns. I read some forums about how some surgeries were done badly, how people still had pain after surgeries and how it was worse than before!! *gasp*

Ultimately, while it took me more than a month to consider, I decided to go ahead. My main rationale was to get it done early, especially when I am still young, fit and healthy. Many of the people who had very dire complaints were of more advanced age or with more sedentary lifestyles. Recovery might come more of a concern later in life, particularly if the tear worsens. This thing has been plaguing me since 16 or so and I think it just broke through a certain threshold when I came to the US. Hence, I thought might as well reduce the risk of further damage now. Also, the university insurance coverage seems to mean I don't have to pay much at all - that eased my financial concerns. The last push factor is second opinions I got from my other doctor friends (a sports medicine doc one of them, thanks A and YM!!) and my friends who have known people who did the surgeries and said they worked well for them. They did caution that the physical therapy is the life-saver for them. I must keep that in mind.

Pre-op, I had an MRI and an X-ray done. X-ray didn't show up anything, but MRI did. I was told that, the tear was not near blood vessels for healing (inner rim of the meniscus; blood vessels on outer). For healing to occur, the tear would have to be sufficiently close to the blood vessels for nutrients and materials brought by the blood to help in the healing process. Alas, the tear would have to be snipped away (menisectomy) instead of being stitched. Finally, I was given a rough idea of the recovery time for a typical person: within a week I would able to limp without crutches, within 2 weeks walk, and within a month jog lightly. I like that. I like knowing my schedule, so I can plan my stuff around it, and putting extra time to buffer.

- Different kinds of tears -
I was imagining mine to be like (d), but when I saw it on screen, it looks like (b), so maybe a combination of both like (c)??
(Source: http://en.wikipedia.org/wiki/File:Meniskusruptur.svg)
I have tried explaining this to my mum what I think is happening, as lay as possible. I think it makes sense, so I shall try explaining it here too. The (two) menisci act to distribute the force exerted by both the tibia (calf bone) and the femur (thigh bone). So when you have a tear, you experience some form of discomfort when the bone brushes over a tear instead of a smooth fibrocartilage. Snipping away does reduce the size of the meniscus but it beats leaving the tear there. I liken this to a piece of paper. When there is a small partial tear, it is much more likely and easily that the paper will be torn further via that tear, then if a new tear were to start someplace else away from that tear (try with a piece of rough paper). Snipping that tear away will reduce the probability of further damage to the cartilage via that tear. However, it does reduce the cartilage area, hence your cartilage will not as resilient as your original whole cartilage, but to damage it, the impact would have to make a new tear instead of worsening an old one.

Before the surgery, I had to do the routine pre-op within 30 days of the surgery - draw blood to test for cholesterol levels and the likes. Happy to know I was good to go. 12 midnight on the day of the surgery, I was to stop eating and drinking - basically just sleep with no supper and breakfast.