THE TERRIBLE MIDDLE

HARD INDEED, it is to find a proper name for a phase like The Terrible Middle. Whatever the right name, here I am in the Terrible Middle...perhaps The Dreadful Middle, could that be the right term?

Those of you who have been here will know what I am getting at. Back when I rode century bike rides with my mates in Portland, I came to understand the existence of this Middle. How does one ride 100 miles? Or run a marathon? Physical training is important but can be overemphasized. Psychological conditioning is most important and often this comes down to understanding The Terrible Middle. Thirty three miles to warm up, then thirty three of the The Terrible Middle, and then "Well, anyone can ride 33 miles.".

Right now, my Terrible Middle looks and feels like this: Surgery done, walking about a bit, off drugs, only need pain medication occasionally, driving the car for shopping and library, but only able to sit, stand, walk, read (long list could continue) for short periods. Little engages my interest, I read but do not take in, chocolate does not yet taste like chocolate should, I eat because it is time to eat, food is boring...how the litany flows on! Folks, let me introduce you to my my Terrible Middle.

The only good thing to say about the Terrible Middle is that it is a Middle. How far can one venture into a forest? Well, just to the Middle...after that one is on the Way Out. One of my favorite TV shows is 'Man Against Nature' (a silly title, really, since man is part of nature). The heroic adventurer is in a dense Bolivian jungle, for example, and climbs a tree to see where he is in the forest; or shows us a way of keeping going in the right direction to exit the forest. Knowing the forest from the trees seems like a very good idea. Understanding the Middle and how not to go around in circles could be one of the great secrets in life.

This is not confined to long cycle rides or recovery from surgery. Where are we in the Great Financial Crisis; what about the Great Oil Spill; and how about the ordinary business of getting older? Unfortunately, despite our expectations from our youth, Terrible Middles abound and may even pass unnoticed.

What we do in the midst of the Middles, retrospectively, can be critical. Learning to save instead of spending, engaging in kindness to others, taking a walk in the sun instead of being indoors watching Telly, talking with a neighbor, and the like. Generally, doing other than what we prefer to do or are wont to do bears on the secret of surviving the Terrible Middle.

For those in the Terrible Middle of middle age, let me recommend Barbara Strauch's book, "The Secret Life of the GROWN UP BRAIN". Not only will this book slay many myths and fears about the aging brain, but also light up the path of things to do to exploit the strengths and properties of the mature brain.

Middle Age happens not to be a problem for me. On Saturday I trip over my 73rd Birthday and thus near the final quarter of my life. I am having a lot of fun dreaming up what that will be.

On the knee front, what lies ahead is the work of rehabilitation, especially restoring a good range of motion through physical therapy, extending my walking range, and also arranging the next ordeal for the right knee. I see the surgeon next Tuesday and hope that the good progress made with the left will persuade him to press on with the work on the remaining knee.

NEW KNEE: DAY 8

TUESDAY: Just over one week since the surgery.

Yesterday the local area nurse came by to change the dressing and check progress (measuring various circumferences and the like). An opportunity to get pictures and here they are...not exactly what one might call pretty! I have 14 staples closing up the skin and they are due to come out toward the end of this week. The underlying sutures closing up the deeper layers will dissolve. As you can see, there is a deal of bruising. What you can see from the back of the leg is due to the tourniquet used to stop the flow of blood to the knee during the procedure. There are other areas of bruising related to retraction of the sides of the incision to expose the operating area ands on the shin and ankle where the jigs to do with the carpentry and assuring alignment were sited.

Seeing all this bruising has reinforced in my awareness that one serious risk of the procedure is the formation of blood clots that could cause a lot of trouble in the leg and other parts of the body (lungs, heart, brain, and so on). I have been careful to take my blood thinning medication and to do the exercises that offset this risk.

I am pleased to report that the wound is healing well and swelling seems reduced each time the leg is measured. It is good to be able to slack off and spend lots of time napping with my feet elevated. I now am able to walk with more or less respectable form without the aid of a stick but the stick still proves to be a good tutor as to the proper way to walk. Life is a not unpleasant routine of my five physical therapy workouts followed by some time lying with feet elevated listening to a recorded book, interspersed by short walks hither and yon (like out to the mail box).

Pain management has been excellent; I must admit that I was prepared to experience considerable discomfort and it has be a welcome surprise to have very little pain. Discomfort seems to unravel or become apparent in 'layers'. By the middle of last week, this had resolved into deep muscle pain. Toward the end of the week and over the weekend, it was related to the bruising of the outer tissues. Just recently, it has to do more with the actual incision and I will be pleased to see those 14 staples on their way! Pain puts a limit on how much the knee can be flexed but flexion happens to be the name of the game. Small advances are acceptable and achievable. Really, I am very happy to report, pain has been no 'big deal'.

I discovered one aspect of healing that I could have anticipated from my reading around depression. Healing of serious injuries results in a process around the wound site that eventually sends messages to the rest of the body to slow down (via substances called 'cytokines') so that energy can be conserved toward the healing process. This have a side effect of depressed mood. I had forgotten this until I noticed that I was not enjoying the taste of food and was finding it hard to focus when reading. I ordered up some baking chocolate (very dark) and made sure I spent some time out the sun, as well seeking the company of my neighbors when outdoors. At first the chocolate did not quite taste like chocolate but the pleasure of its taste, I am glad to say, has returned.

I did get a little 'cabin crazy' yesterday. I found, however, that I could get in an out of the car without too much difficulty, so took my self off down to the local coffee shop for good coffee, my favorite cinnamon roll, and conversation.

It turns out that getting over the insult to one's body that surgery happens to be is quite complicated and, no matter how impressive the surgery itself may be, it does require quite a bit of personal effort and dedication in the recovery phases.

From now on, I promise, only occasional reports; it may be that there are more interesting things to write about. If you have a question, put it in the comments section and I will answer it the best I can.

DAY SIX: RECOVERY CONTINUES

APOLOGIES that I am not able so far to present a picture of my 11 cm or so incision. You will have to wait for the next post for that.

So...here I am on the morning of Day Six (Saturday); and glad to report that I am doing quite well. On Day three, you may well recall, I was still using crutches. Feeling and control was returning to the upper leg. By the end of the day I was making only limited use of the crutches and thinking that I might well do without them. However, I had no walking stick and did not feel sufficiently venturesome to just do without them.

On Thursday, I found that I was confident to do away with the crutches some of the time, using only on and, from time to time, just walking short distances without them. Still on pain reducing tablets of various sorts. However, Wednesday night was the last time I used Oxycontin and I ceased Oxycodone on this day. This was also the day Doug, the the Physical Therapist, visited. He gave me a stick, three sets of exercises to do five times each day, and coaching on recovering a normal walk and going up and down stairs. He promises to be quite the tyrant so I am working to meet his criteria in time for his next visit on Monday. This was also the day that I ventured out to pick up the mail from the cluster of mail boxes across the road (slow progress and several snails rudely hooted at me as they passed me by).

Yesterday, Friday, was consumed with rituals to do with physical therapy, ice treatment, walking about and discovering how truly boring Friday TV can be. The longing to get some work done began but frustration at not being able to just sit for more than 10 minutes also set in. I find I can now redo my pressure bandage. Last night, I slept without it. Also, just on Tylenol every six hours now.

Now that I can view the knee, what do I notice? Quite a bit of bruising from the tourniquet application above the knee (the operative area has to be virtually blood free), as well as some bruising of the shin where the alignment tool was fixed. Swelling is greatly reduced but quite present still.

I thought I might be worried about putting weight on the leg (despite that I know the glue used sets in 5 minutes or so). In fact, the procedure results in the knee being considerably restricted in motion due to swelling and associated pain. This is mainly due to the incision itself (lots of stitches) and the trauma to the soft tissues being pulled and pushed about. The nerve block obscured this over the first two days and the magic 'Oxy's' take over after that.

The main problem is to minimize and then reduce the swelling and the ice treatment (a cuff placed around the knee that has ice water pumped through it from a Kooler-like tank)i s really good for this and I am sure the pressure bandage helps a lot too.

It helps to remind oneself that the pain originates from the soft tissue and not from the bone and that the various bits of the prosthesis are securely set in the joint. With a partial knee replacement, no muscles are cut and all the natural ligaments holding the joint together are left in place. The actual experience of pain is far less than I had anticipated and it really is very encouraging to discover that one can move about so soon after the procedure.

As there is a good chance that some of you will have this procedure, or one like it, over the next ten to 20 years, I hope that my little saga will be helpful if you recall it when considering what best to do. It is helpful to a lot of research beforehand.

In the meantime, this saga continues...watch this space!

NEW LEFT KNEE: DAY 3

WEDNESDAY: DAY THREE

RECAPPING (couldn't resist the joke!). It was early rising on Monday to get to the Outpatient Surgery Center of Strong Memorial Hospital...a modern and imposing building on the southeastern side of Rochester, commissioned last August. I half expected to have a valet parking service, so like a plush hotel is this center, but no, unassisted, I hobbled inside to join the few first arrivals.

A few formalities and I was soon called to go down to the cubicle where all the medical preliminaries were to take place...blood pressure and all the other vitals; getting to meet the first of the long line of staff who were to look after me, everybody warm and cheery. Musing a little on those nice premeds, I began to think that this was going to be quite the party. I do admit to being somewhat apprehensive but the brisk pace and the friendliness of staff greatly diminished this feeling...rather like finding oneself on a pleasant conveyor belt. The nursing staff took lots of trouble to ensure that it really was me and that it really was my left knee that was to have the procedure, drawing all sorts of hieroglyphs on my left leg. Then two anesthetic teams (one for the regional block and the other for the general anesthesia) and finally Dr. Drinkwater to discuss the surgery once more and to leave his initials on the target knee. That day, the surgical unit had 28 procedures to do and have done up to one hundred on some days...quite a production line. I hope you like the picture of me (courtesy of Uma) holding up the saline drip! Next blog posting, expect a picture of the incision; I have to wait for the district nurse to change my dressing to get a shot of the knee.

With the aid of ultrasound, the regional block team laid a slug of something like long acting Novocaine alongside my left femoral nerve (done very, very carefully), the other anesthetic team shot in the premeds and, right on time, I was transported down the corridor (all those ceiling lights flashing by) through the double set of double doors to the OR. This I observed to be spacious, filled all sorts of shiny equipment on the one side of the waiting operating table, and also rather like an office with a desk on the right hand side. Once on the table I seemed to be surrounded by a host, two of which gave me a friendly invitation to take deep breaths from the plastic mask and...the next thing I knew it was 10:30 and I was in my recovery cubicle.

The nerve block ensures that I had no feeling and no pain. It really was long lasting but also paralyzes the quadriceps so I was quite unable to move the lower leg upward all of Tuesday...a little disconcerting. However, I had two follow up calls from the anesthetic team and the surgery team and these reassured me that it may be up to 36 hours before feeling and motor control would come back to the leg. These resulted in a third call from Dr. Drinkwater's medical secretary warning me to keep up with the pain medication as feeling, once it began to return, would do so very quickly. This it did overnight. Nicely cushioned by magic Oxy-s (-contin and -codone) I slept the night through and found my leg was beginning to work this morning.

So I am getting around of crutches and gradually able to place more weight when walking with my left leg. The nurse returns tomorrow to redo the dressing and the physical therapist makes the first call for rehab on Friday.

Time for some more ice therapy and my exercises to keep blood moving around my lower leg. Thanks for all your good wishes and more later.

ON THE EVE OF THE NEW KNEE

TOMORROW is the day of of the new left knee. The procedure will be at 7:45 AM on 10th May. I confess to being more than a little awed by the prospect, plus feeling what I suppose is the normal anxiety.

I have had various troubles with this knee since 1992 when it was arthroscoped; I recall the surgeon prophesying then that I would develop osteoarthritis eventually. I reckon I have had a good run from it since then. Doing some final work around the garden yesterday, it seemed that it really had worn out.

I have collected together all the bits and pieces (crutches, drugs of various sorts, ice treatment equipment, and so on) and will soon be off to Rochester this evening. The last few days, I have been washing the area of the operation with chlorhexadine to make sure I am not carrying any bad bugs in with me and working out in the gym with special attention to ensuring good muscle tone, so I think I have done my part.

The procedure is for the Oxford Partial Knee Replacement and has been almost 30 years in development. It will be done at a Surgical Outpatient Unit of the University of Rochester and will involve resurfacing of the femur on the inside of the knee, using a curved stainless steel prosthesis. The top end of the tibia will have a stainless steel tray cemented into a L-shaped cut. When it is all properly spaced and aligned, a special low wear polyethylene insert is placed in the tibial tray and the wound closed up. This will be able to move about in the tray and provide a natural motion to the knee as it flexes. All this takes about an hour. I will be expected to stand on the leg once I recover to a reasonable level of consciousness.

When I am up to it, I will tell you all about the aftermath. When I have rehabilitated this knee I will line up for the same procedure on the right knee. Watch this space, as the saying goes.

I am sure you have found this most interesting (said somewhat tongue in cheek); after all, it is just another of my adventures

ANOTHER SPRING and a NEW PATH

ACCORDING TO the Weather Channel, the spring season has gotten a head start here abouts. The local trees are two to three weeks ahead of the usual time for setting out buds and several varieties of trees (such as cherries and dogwoods) are already in flower. In retrospect, the Winter did not seem as cold as the previous two cold seasons I have experienced here. Apart from a late deep fall of snow while I was off skiing in Canada, the falls of snow were lighter and fewer. The link between weather and climate may be difficult to infer but it is hard to avoid feeling that there may be something to this global warming after all.

Last Autumn, the Canadian Red Cedars showed such an abundance of seeds (colloquially, 'wing-nuts') that the squirrels and chipmunks just could not keep up with taking them off and burying them. While what little snow we had was lying about, it was intriguing to watch them sniffing about, then diving into the snow to come up with yet another nut and that 'Tom Thumb' look on their little faces. Now that the snow is gone and the lawn is about ready to get going, our neighbor, Chris, and I got busy with the lawnmowers (in suck-up mode) to clear up the wing-nut debris (ours, of course, destined to become compost). Since the squirrels did not have to dig up seeds they had buried, we have a crop of red maples coming up all over!

The neighbors have also been busy with their mowers. The race to be first was, as usual, won by Peggy who lives just up the street, on the other side. She was out on her ride mower even as I was contemplating getting our mower out of the shed for post-winter maintenance! Now the sound of lawn mowers can be heard most days. I am not too sure just why, as the grass has barely begun to grow! I reckon it will be two weeks or more before I will turn again to it. Amazingly, it started first pull on the starter cord!

A NEW PATH: This blog started as a means of keeping you apace with my adventures. We have been off on a few...travel, reading, politics, global warming, and so on. I find it most interesting to review my various wanderings by looking back on past postings so it has worked well for me too.

Now I am about to start a new path. As most of you know, these last two years, I have been living here in Painted Post ; this has been a most happy time for me. Now my path is leading back to live once more in Australia. I have been living in the US since February 1995, first in Phoenix, Arizona, then in Oregon, and now in New York State. Most of that time I have lived in Portland, which must be one of the most beautiful and livable cities in the US. There I was fortunate to make wonderful friendships and to renew valued friendships with some who lived in Australia at one time or another but have returned to North America.

There are a few challenges to meet (ridding myself of a bunch of stuff, planning the future, and the like). Having worn out my knees over this last decade, the most pressing is the business of knee replacement. On Tuesday, I go to visit an orthopaedic surgeon to see what must be done. One way and another, I have tracked down a surgeon who happens to be an Australian so we probably will not need an interpreter. I will keep you in the picture on this front. I hope to have this done, along with the rehabilitation, by my birthday (May 29).

So I am planning my exit from the United States. This will be somewhat leisurely. Late July I will drive back to the Northwest, visiting several National Parks along the way, to spend some time visiting those of you who live between Vancouver and San Francisco. Finally, I will continue on to visit with my daughter, Bronwyn, and my eldest grandchild, Stephanie. Then, mid-September, it will be back to San Francisco and the United Airways flight to Sydney.

Besides keeping you up on all this, I will probably write on my American experience, my thoughts about my new future, and perhaps even the meaning of life.

OLD KING COAL

NOT 'OLD KING COLE' of the childhood nursery rhyme:

In this posting, I am reviving earlier discussion of climate, global warming, and whether there is anything we might do about it. The focus is on coal and natural gas, and possible alternatives in our energy future, with implications for the exercise of democracy.

Both the US and Australia are very dependent on fossil fuels, notably coal and natural gas, for the production of electrical energy. As more vehicles become powered by electricity, the transport system (private cars, public transport, trains, trucking) will shift from its current petroleum base to electricity. Conceivably, during the day and especially at night, millions of vehicles will be plugged into the electrical grid for recharging. Unless this new load is balanced by a reduction in other areas of demand, such as lighting, heating and air conditioning, and the use of electronic devices, this will result in a rising demand for electrical power.

It will be many years before substantial power will come from 'soft' or renewable energy from wind, solar, waves and tides. A difficulty with such sources is that they are not constant. The wind does not always blow, for instance, and the sun goes down at night. The times when demand for electrical energy increases may not coincide with output from soft energy sources. Also, when this output is in excess of demand, it is difficult to store. In an electrical system generation and load must always be in an exact balance. This can achieved relatively easily when the generation is controllable. The increasing use of smart grids will add control to the demand side. A significant problem with soft energy generation is finding ways to store excess power as when generation exceeds load.

Several factors make coal king: It has very low cost (ignoring health health and environmental costs), it can guarantee a constant base supply, and it is relatively easy to light up a furnace to bring on extra power. In fact, the ability to respond reliably to peak demand puts a premium price on a power station's output and leads to a strong profit bottom line. Natural gas has some advantage over coal in that new power generation based on this fuel are cheaper and quicker to build, run cleaner in terms of nasty emissions, and can come on faster to meet peak loads. However, natural gas is more limited both in terms of supply and in long term reserves.

In a world with constantly increasing energy demand, emerging economies like China and India will likely look to coal. I have read that China is building coal-fired power stations at the rate of one per week. In the US, one per cent of atmospheric contaminants arrive from China.

The big problem with electrical power from fossil fuels is that loading our atmosphere with billions of tons of carbon dioxide each year may be accelerating global warming and perhaps will bring us to a "tipping point' beyond which no action of ours can claw us back. If we weigh the various cost-benefit ratios that arise from the often murky debate about global warming and its possible effects, the sensible choice must be to develop alternate energy bases in order to avoid global disasters. This would involve reducing and perhaps eventually replacing fossil fuels.

Is it time to dethrone King Coal? Kings have been overthrown in the past. But how?

Two clean-fuel possibilities that might replace coal are geothermal and nuclear. As to the first, not too far below the earth's surface are hot rocks that can be fractured to allow the passage of water from one point to another. Drilling down to these rocks uses technology developed in the oil and natural gas industries. Steam generated in this way can drive turbines to produce electrical power, as is the case at many places around the world.

Nuclear power generation is more controversial. How controversial depends on where one lives. Not very in France, a net exporter of electrical power to the rest of Europe, where nearly 75% of electricity is produced at nuclear plants. Very controversial in Australia, which is odd as this country has 30% of uranium ore reserves and Canada which has 40%. Especially odd when one considers that the Land Down-under is more dependent on coal, and has lots and lots of it, than the US. Somewhat controversial in the US, where there are some 59 nuclear power stations (about the same number as in France).

But what about Three Mile Island and Chernoble? The actual risk is very low compared with the tens of thousands who die or are made sick through coal station emissions. We humans are strange around risk. For instance, we do not hesitate to drive to the airport while thinking about possible plane crashes, despite that the former is thousands of times more dangerous. About 115 people die on the roads each day in the US, including some 30,000 teenage drivers each year.

James Hansen, in his book 'Storms of My Grandchildren', points out that modern fourth generation 'fast' nuclear reactors are a hundred times more efficient that older types, produce waste that is far less toxic and which lasts only two hundred years (compared with thousands of years), and is readily vitrified for safe storage. Moreover, such reactors can 'burn' all the toxic materials produced by older designs. With such reactors, there is fuel for a thousand years and possibly ten times longer longer.

These reactors can be built in the very near future. A project reactor was ready for assembly in the US but was 'axed' for political reasons by the Clinton administration in 1994. It is an interesting conundrum, is it not, that we are more afraid of the nuclear bugaboo than we are of possible termination of life on the planet, or at the very least, civilization as we know it through needless carbon emissions?

It is strange that so-called 'environmental' groups are the most politically and influential in the 'battle against nuclear'!

No political debate preceded adoption of coal and oil as the energy foundation of our present age. These were imposed on us by the captains of the industrial revolution and have occasioned much suffering and afflictions ever since. How different things could be now. Through the Internet, we can all follow scientific discussion and contribute to political debate. Or we can 'fiddle', as did those three in the old rhyme...

"...

Every fiddler had a fiddle, and a very fine fiddle had he,

Oh there is none so rare as can compare

With King Coal, and his fiddlers three!"