Septic Arthritis (these events happened in March 2007)
I woke up shivering. I was in London at my cousin Selvan’s place, lying in bed wondering why I felt so awful. I moved, tried to get up, but my left leg hurt. It would not bend properly. The shivers passed through me in a constant wave making my teeth snap. I limped over to the shower careful not to put pressure on the left leg, careful not to bend it too much. It was hot from the calf to the knee, visibly swollen and red. Turning on the water and standing in the shower, balancing on my good right leg, provided temporary relief. I could breathe again.
I spent 3 days trying to get over the fever. The pain when walking was unbearable and my most comfortable position was on my back. On the third day I saw a GP. I described my symptoms which included a fever, the shivers, the excruciating pain when walking and the fact that I had recently arrived from New Zealand. He had a brief look at the leg, asked a routine set of questions that I can’t remember now and wrote a letter, printed it and gave it to me with instructions to go to the A&E at Kingston Hospital. “Can I get some painkillers?” I asked. “Better find out what it is first” he replied. “Is it bad?” He paused for a bit and then said, “Maybe”. I left the GP and went to Kingston Hospital. Getting in and out of a car was an ordeal. I would first rotate my legs out of the car. Then holding onto the door frame for support I would haul myself up, using only my good leg for support and trying to minimize the bend in the left knee. I had a look at the letter the GP wrote. It said that I was to be treated immediately for suspected deep vein thrombosis (DVT). The part that said ‘treat immediately’ was a blessing. Those who have ever been to the A&E in London know that a 3 or 4 hour wait before being seen is common and I was glad I did not have to sit in the waiting room hours before being seen by a doctor.
The doctor at the A&E asked questions and I gave the same description of the symptoms. They did two blood tests, one from my vein and another from an artery in my wrist. Things seemed to get more serious as time progressed. It took an hour and a half for the results of the test to come back. The doctor said it was inconclusive for DVT although it was apparent that I had some sort of infection. My C-reactive protein (CRP) count was 450 mg/L. The CRP count is an indicator of infection or inflammation. A normal reading is less than 10 mg/L. My heart rate was beating at about 100 beats per minute so I had an ECG done. It showed no anomalies. The next surprise for me was the preventative anti-coagulant they administered via an injection to the stomach. It didn’t hurt. Then they put me into a bed and inserted a cannula and dripped the standard saline solution into me. By now I was wondering thoughts like Why are they doing this? Does this mean I get to stay the night?
I stayed the night. Shortly after being placed on a drip I was wheeled on my bed from the A&E to the medical assessment centre (MAC). By now it was late, about 20h00, and I was hungry. I had not had anything to eat since lunch and, because I was ill, I was not eating much anyway. In the MAC I was placed in a mixed bay with about 6 other patients, all elderly. One of them was a women who kept trying to take her gown off and the nurse, constantly had to tell her “There are men here, put your clothes back on”. She did this about 10 times. Later in the evening, at about 21h00, another doctor came to see me. He had a look at my leg under the bed light. “Looks like cellulitis in the left leg to me. I can see why the GP must have though DVT since you’ve arrived from a long flight.” I was placed on intravenous antibiotics for treating the bacteria causing the cellulitis in the leg. It was Tuesday the 27th of March 2007. The women in the bed next to me who kept trying to take off her clothes was moved from the ward. I think I must have dozed off but later woke a little later that night when someone else was wheeled in next to me. The next morning he was dead and in the afternoon they wheeled him out in a black body bag.
I think I stayed another night in the MAC before being moved to the Winter ward. This was a difficult journey because the lifts in the hospital, being somewhat prone to illness, stopped working. Before they could wheel me back, I made a little noise that was probably construed as a protest and said “I’ll walk the stairs.” Despite the obvious pain walking caused I knew I could pull of at least 1 flight of stairs. Grabbing onto the hand rail for support and being careful not to use my left leg for anything more than a temporary support I winced my way up the steps onto the next floor. From there they wheeled me in a chair to my new bed.
I knew I was in for a hard time in my new bed the moment I cornered the edge of the door. There were 6 beds in the bay, 3 on the left and 3 on the right. Mine was the middle left. To my right was an old man with no pants on lying in his bed and muttering and cursing to himself in a faint Irish accent. To my left was an old man sleeping so still that he could pass for dead. The whole bay was filled with old men. I must have been the youngest in the bay by 50 years.
It wasn’t long before the man on my right, called John, started yelling abuse at the nurses. This was a constant phenomenon for the 3 weeks I was next to him. I think they had removed his call bell because of the frequency he would use it and the constant abuse a well meaning nurse would receive from him. Often dialogue would go something like this:
“Someone help me up, help me up, help me up, help me up.”
Apparently he needed help to get out of bed so he could pee in his bottle. The ‘bottles’ were an thick egg cartoon material that males could pee into without having to walk to the toilet or even get out of bed. If no nurse arrived in time he’d pee in the bed. When the nurse arrived he would castigate them furiously saying,
“You brought this on yourself I tell you!”
On another grey London day a male nurse from Scotland was in the bay, working the IV and dispensing drugs to the patients. Unfortunately he managed to press John’s anger buttons, of which there must have been many, and John flamed at him
“Why don’t you go back to Scotland!”
John even had the balls to tell a chaplain to go to hell. She came to him offering communion.
“Hello John,” she said in her pleasant as custard and cake tone, “I’m the chaplain here to offer communion”.
“I don’t want communion from you,” he burst forth, “You’re a protestant and I’m a catholic!”
“Now John there’s no need for that”, the old man opposite him said, “It doesn’t matter.”
The chaplain was standing still flabbergasted by the verbal assault. I think she may have taken a step back in shock.
“Of course it matters,” he replied, “There’s a big difference. If it’s Catholic it’s the body and blood of Jesus otherwise it’s just bread and water.”
By now the chaplain had recovered some of her composure and she said, “I’m sorry you feel that way. I’ll go now.”
“That’s right. Piss off.”
I was sick of his yelling and belligerence after a few hours of being in the bay. When some friends came to see me on Wednesday we naturally started talking and laughing a bit.
I heard John start muttering something along the lines of, “There you are laughing and giggling away can’t you keep quiet!” I wasn’t going to let him get away with anything.
“Fuck you!” I yelled back.
I didn’t care if he was geriatric, if he wanted a conflict I wasn’t going to disappoint him. I yelled loud enough for people outside the bay to hear.
“Nobody likes you!”
That shut him up. When my friends and cousin left, John apologized to my cousin as he passed John’s bed. Although I did give him a dirty look when I passed his bed on the way to the toilet on one occasion, and yelled at him “You’re a weird man”, I wasn’t going to have a permanent war with him. Part of me realized that he was old and frail but his mind was still intact and I think it frustrated him not being able to do the things he would ordinarily do with ease. There was an occasion when he stood up and was looking for a bottle to pee in. He could not find one so I handed him one of mine. I also brought him some fresh water once when I walked passed his bed and he asked for it. However being old and frail didn’t excuse his rancid behaviour. There were other old people in the ward that behaved normally.
Being in hospital is a battle. You’re fighting several enemies. Firstly there is the illness that put you on a bed in the ward. This can range from something imaginary where a patient thinks he is sick and wants to be in hospital to or to something severe like a stroke. I saw a mixture of patients come and go while in the ward. The majority of the patients were elderly, 70 years and older. There was a patient with cellulitis in the leg. He stayed about 5 days before being discharged. Another patient came in after surgery. He had had about 24 cysts removed from his upper body and stayed about 2 days before his wife took him home. There was a 94 year old who had the mind of a 20 year old. He constantly hit on the nurses, saying things like “Come back to my place after I’m discharged. I’ll make you dinner and teach you French. I have French blood” and “The sight of you warms me up”. He lost his teeth one day and that caused some consternation amongst the occupational therapist and nurses. One day he walked around smiling at all the nurses until one of them pointed out that he had no pants on. He promptly sat on his bed and tried to use his shirt as pants. It wasn’t working out too well but fortuantely one of the nurses pointed out his mistake. It was always a laugh when whenever the nurses came to talk to him. Another patient came in and had a ‘fall’ next to his bed. He told the nurses and doctors that he could not walk. One morning I watched him as he got out of bed and shuffled sideways to his chair and sat down. However, for some reason, walking forward was beyond him. The nurses thought he was faking it and the doctors could detect no injury from his ‘fall’ that prevented him from walking. Another patient came because his GP called an ambulance for him. He managed to talk to everyone in the ward who would listen and he liked to emphasize the fact that he was there because his GP had called an ambulance and therefore his case must be serious. Apparently he was there because of the after effects of a gastric flu he had had 3 weeks ago. When he told me this I wished he wouldn’t sit so close and talk to me. The doctors didn’t treat him for the after effects of gastric flu because there was nothing to treat. Instead they diagnosed an anomaly in his blood tests resulting from the epilepsy medication that he had been taking for 10 years. He took great pains to tell everyone in the ward, nurses, doctors and pharmacists and anybody who would listen to him how dangerous it was changing the dosage and that it had to be done in a controlled way. He was discharged after about 2 or 3 days.
Secondly there is the boredom. A lot of time is spent staring at a ceiling or a wall. The most exciting times in the day are when the doctors do their rounds and visit the patients. This is when you get to talk to someone, tell them how you’re doing, hope that they’ll find out what’s wrong and fix things so you can go home. The other exciting times are meal times. You are presented a menu and get to choose one of three courses for dinner or lunch. I thought the food was quite good despite what everyone says about hospital food. Once they forgot to give us lunch, which made things even more exciting than usual. Other than wait for meals and talk to doctors and nurses there is not much to do. Visitors, people who like you, are a great source of support and are good at relieving the boredom. After 2 weeks in hospital my mother flew over from Australia and she stayed for the remainder of my stay. You can read if you have some books worth reading. It took me a while to find a book worth reading, but eventually I found The Silence of the Lambs and that entertained me for a day and a half.
Third is the constant disturbance from mad patients, like John next to me, who keep you awake at night with their moaning and yelling at nurses. It was 1 am in the morning when I heard a motion next to me. Standing with no pants on next to my bedside table was the man from the bed on my left. He was drinking from my water jug and spilling down his chest. I was a bit shocked and not knowing what to do told him,
“Go to the toilet”.
“Where is it?”
He’d been in the bay a few weeks and still didn’t know where the toilet was.
“That way”, I pointed in the direction of the toilet.
“Oh”, he said and shuffled along without trousers. The initial shock of him stealing my water at midnight made me wary of him for a few days but after a while I realized he was harmless funny old man. Later in my stay a patient with dementia arrived. He often forgot where his bed was and was inclined to wander over to other people’s beds and take their things. He tried to take some of John’s things from John’s precious bedside table and a verbal tornado of abuse ripped forth “Go away! Those are my things! Piss off back to your bed you useless thing!” After John left, which took 2.5 weeks, the bed on my right was filled with a man from Sri Lanka who was suffering from the after effects of a stroke. He could not stop talking and would babble loudly in Tamil about nothing. He did this all day and all night. None of the nurses could communicate with him. He could not move so he would go to the toilet in the bed resulting in a suffocating assault on my sense of smell and 3 nurses coming in to clean up the mess. One night, a nurse came into his bay to check on him.” “Oh god,” I heard the nurse murmur, “Oh god. Why did you do that? There’s blood everywhere.” The man had pulled out his catheter. A catheter is a flexible tube inserted into the urethra and allows one to urinate into an external bag. Pulling it out ruptured things internally causing him to bleed profusely from the urethra. He really was in a bad state.
On the 1st day being in the Winter ward one of the junior doctors came to assess my condition.
“Hi.” she said, “How do you feel?”
“There’s less pain in the leg,” I said, “although it is still swollen. The redness seems to have gone. It still hurts to walk.”
“That’s good. Looks like the antibiotics are working.”
A few minutes later her registrar, a more senior doctor, came in to follow up. He had a look at the leg and my temperature chart and said, “We need a scan done on the leg just to make sure. Also his temperature is spiking. Double his antibiotics.”
I’m not sure if I heard the next part correctly or not but I think he said “And scratch that ‘recommend for discharge’ note”. I may have misheard but it was somewhat disconcerting to think that the junior doctor had missed the temperature spiking and possibly recommended that I be discharged when I could not walk because of the pain.
I think by now I was on 1.2g of benzyl penicillin and 1.0g of flucloxacillin administered intravenously. The next day, Friday, I was scheduled for an ultrasound on the deformed leg. I was placed on a wheelchair and given a blanket to wrap myself up with. It was cold between wards and the trip to the radiographer’s lab was long. Because I could not bend my knee fully I had to keep it away from the footrest on the chair. There may have been a light snow outside. The radiographer scanned my leg with the transducer looking for DVT. She moved the transducer over the back of the knee. “Look at this” she said to the other radiographer in the room. The other radiographer moved to look at the image on the scanner. “What is it?” I asked. There was a pause while they both looked at the image on the screen. “It’s fluid in the knee. That’s why you’re in so much pain.”
Armed with this new knowledge and the feeling that I had finally found someone who understood the pain I was in, I went back to bed and waited. It was Friday. The doctors had already done their rounds in the morning. The next day would be boring because the doctors do not do rounds on the weekend. I would have to wait till Monday for the next stage in the diagnosis. I played on the PSP. My cousin had bought this neat wrestling game, Smackdown vs. RAW, that I ended up playing to the tournament’s end. It had a massive variety of ways to customize a player created wrestler, from the introductory walk into the arena to the attire and allowed the player to assign from hundreds of moves, like backbreakers, suplexes, punches and chops, kicks and mudhole stomps.
When the pain in the knee was too great I could ask for tramadol or dihydrocodeine. They are both painkillers used to treat moderate to severe pain and they helped relieve the pain present in the knee when it was not bent beyond its limits. My guess is they are better at relieving visceral pain rather than joint and muscular pain. There was nothing to relieve the pain if I did try to bend it beyond the limits imposed on it by the fluid build up. By Saturday afternoon I felt more pain in the knee and asked for painkillers. They brought a welcome relief. I think the nice nurse gave me a combination of tramadol and dihydrocodeine which was awesome. I found that I could limp my way to the toilet without wincing and for a while I was happy.
Midnight came and I was hurting badly. The effects of the painkillers had worn off. I couldn’t sleep because of the pain in the knee. I wish it would go away. Maybe if I wait a bit it will go away. I waited till 2 am still not sleeping and tossing and turning trying to find the least painful position for the knee. Eventually I gave up trying to get through the night on my own and called the nurse.
“What’s wrong,” she asked.
“My knee. It’s more swollen and it hurts. I’m in pain. Maybe call the doctor.”
“If I call the doctor he’ll recommend a painkiller. So what I’ll do is give you a painkiller and if the pain is still there then we’ll call the doctor, ok?”
She gave me two pills of dihydrocodeine and left. About an hour later I was still hurting the painkillers having no effect. I pressed the call button again. This time a different nurse came in, one who was not allowed to administer drugs.
“What’s wrong?” she asked.
“I’m in pain. My knee hurts. I just want it to go away.” My voice was weak and barely above a whisper.
“I’ll call the other nurse,” she said. As she walked away she asked stupidly “So the painkillers aren’t working?”
“No!” I yelled back angrily.
Sometimes the stupidity of people and their ability to ignore the obvious was infuriating.
It was about 3 am on Sunday morning when the doctor came into the bay. He turned on the bed light and proceeded examining me legs and knee. I told him where the pain was. Then he began tapping a point high on my right leg and the mirrored point on the left leg.
“Does it feel the same?” he asked.
“The same,” I replied. He then tapped a little lower. “And now. What does it feel like?”
“The same,” I replied.
I’m guessing he was looking for some sort of failure in my nervous system. I thought this was a stupid test given that the size of my left knee was 3 times the size of my good right knee. It was pretty obvious that the pain was real, located in my left knee, and not a result of a malfunctioning nervous system. He continued tapping away until he reached my feet and then left. The next thing I remember was an orthopaedic surgeon at my bed. It was about 4 am now. He looked at the knee.
“I didn’t think they would have an orthopaedic surgeon around at this time.” I said in a vaguely impressed tone.
“They keep me here.” he said. “You’re from New Zealand?” “Yes.” I replied.
“I’m half Australian so I can tell the difference between the accents. How much can you bend the knee?”
I tried to bend it but couldn’t. It was locked at a certain angle.
“I’m going to twist your leg to see where the source of the pain is. Have to make sure.”
So he began twisting it from left to right. Once he passed the median point, the point where it begins to twist inwards, I yelled as a sharp pain lanced through the knee.
“Don’t do that!”
“Ok, sorry, but I have to find out where the pain is. I’m going to come back with a syringe and drain the knee.”
He returned and asked me to bring my leg up so that there was an arch between the bed and the knee with the knee at the apex of the arch.
“I’m going to anaesthetize the knee. It will hurt.”
The needle went in from the outer left side of the knee. I clutched the sides of the bed and screamed. Next he pulled out a larger 50ml syringe attached to a needle with the largest bore I’d ever seen. I had a brief flutter of panic. He inserted it into the knee and the syringe rapidly began to fill with yellow fluid. The relief from the pain was instant. I could breathe again. He filled a 2nd syringe with more synovial fluid and moved onto a 3rd. He stopped when blood started to enter the syringe.
“Looks like you have arthritis,” he said.
I asked. “I’m too young for that.”
I was puzzled because I had only ever heard of arthritis in old people.
“Not really,” he replied. “We’ll get the doctors to have a look at you early in the morning.”
I slept instantly.
It was about 9 am and a team of about 5 doctors had swarmed into my bed area. The curtains were drawn. A tall man, with black hair and bald on the top, took control of the situation.
“Hello. What was the first thing you noticed when you got sick?”
“I woke up shivering. Moving the leg and knee was painful.”
“So you noticed the knee first?” he asked.
“It was one of the first things,” I replied.
“Do you know why the doctors are worried about you?” he asked.
“Because the current treatment is not working.”
“Yes. Well it looks like a case of septic arthritis. Being the most senior doctor here,” he said, “We’ll schedule you for surgery this afternoon and open up the knee and wash out the fluid. It should get rid of most of the bacteria, if not all of it. Hopefully a theatre will be free.”
It finally looked like the doctors had found, after 6, days a correct diagnosis. From then onwards I was dealt with by the orthopaedics team and no longer the team from general medicine.
There’s not much to say about surgery because I was under general anaesthetic. After the surgery my knee felt the most comfortable it had felt in a long time. It was wrapped in a pressure bandage. I was surprised by the lack of pain. I expected there to be pain from the surgery. I was wheeled from the recovery room, where you swim through double vision while waking up from the anaesthetic, back to my bed. Another surgeon came to speak to me after the surgery to make sure everything was ok.
“Well what we found in the knee was not normal. There was a build up of pus there,” he said, “but hopefully we’ve washed out the bacteria. We put through 6 litres of fluid and sent the extracted fluid to the microbiologists to see if they can grow the bacteria. We’ve also placed you on a great whacking dose of antibiotics.”
I later found out the amount I was on. The nurses administered the antibiotics by mixing it in a sack of saline solution. Then they labelled it with a yellow label on the sack which stated the name of the antibiotic and the amount and connected it to the cannula in my vein. I was on 2.4 grams of benzyl penicillin and 2.0 grams of flucloxacillin for about 2.5 weeks every 4 hours. Apparently this is a large dose. I had another knee arthroscopy with a wash out 5 days later on Friday. This time they did not find any pus in the fluid build up, however there was a lot of internal bleeding in the knee from the last operation. The pressure bandage after that operation was soaked with blood and it coagulated freezing the bandage solid.
After they removed the pressure bandage the knee was still swollen. The swelling was an after effect of the infection and it had affected the ligaments. They tried different antibiotics in order to improve the results from my blood test. Eventually they settled on a combination of flucloxacillin, penicillin and the ‘drug of last resort’ ciprofloxacin. The goal was to get my CRP count down to acceptable levels. The length of my stay in hospital seemed to be based on my CRP count as well as improving mobility in the knee. I moved around on crutches and was surprised by how weak I had become. I was given physio and exercises to do to regain mobility and strength in the knee. By the end of the third week the nightly sweats I had been having had stopped. My temperature had stabilized and I was no longer spiking. By the time of discharge, after 4 weeks, my quadriceps and calf muscles had withered away noticeably. I’d lost about 8 kilos in the 4 weeks I’d been in hospital since falling ill. A few days after leaving hospital I found that I could walk with a limp without the aid of crutches. Walking for long periods was more tiring than usual. As of this writing it’s been about 6 weeks since I fell ill and 5 weeks since the first knee arthroscopy. There is still a slight, steadily diminishing, swelling around the top of the knee and I probably have about 90% movement in the knee.