Sunday, August 23, 2009

Goulash Recipe

This recipe was distributed to Culinary Institute of America students in Chef Robert Steiner's adult education class "Around the World in Five Nights," taught in the spring of 1983 or 1984. The material includes my notes incorporated in the original document.



Beef chuck cut in 1/4" cubes 1 lb.

Olive Oil 1 Tblsp

Butter 1 Tblsp

Onions diced 1/4” 1/2 cup

Flour 2 oz.

Ground Cumin 1 tsp

Chili powder 1/2 tsp

Paprika 2 Tblsp

Cayenne pepper 1 tsp

Fresh ground pepper & salt 1 tsp (to taste)

Chicken stock 5 cups

Boiled potato in 1/4" dice 3 medium

Sour cream 2 oz

Egg noodles 1 lb.


Sauté beef in some oil and butter, till lightly brown. Set aside, keep warm. Add oil to pan and add onions and sauté till golden brown (clear). Set aside with beef. Add oil and butter to pan, add flour, cumin, chili powder, paprika, salt, pepper, and cayenne pepper. Blend 5 or 6 minutes over low heat. Remove from heat and mix in meat and onions. Add 2 cups of stock and mix until smooth, let sit for 10 minutes off heat. Cover pan and return to heat, simmer for 45 minutes or until meat is tender. Add remaining stock and potatoes. Skim fat, correct seasonings (add salt and pepper to taste). Serve over egg noodles.

Let melted butter cover top to hold from afternoon till dinner. You may add a little tomato paste to thicken, if you like. When serving, add a dollop of sour cream or chives to top if you like.

Sunday, April 5, 2009

My Journey Through Total Knee Replacement

In 1991 I started playing racquetball with a friend who was much better than me. After analyzing the problem, I bought very light-weight shoes to get an extra step on the court. They did not help much, but within a few weeks I was getting a lot of swelling around my knees after our early morning matches. I eventually found my way to an orthopedist who told me I’d damaged the meniscus in my left knee. I had an arthroscopic repair in Nov 1992.

The repair left the meniscus tapered, thinner on the outside than on the inside. Over the years, that unevenness increased, and in December 2008 the discomfort passed my threshold of tolerance. I spoke with a new orthopaedist (the other doctor had retired), Dr. John Crowe, of Orthopaedic and Neurological Services, who informed me that a knee replacement can last 20 years or more – not the seven to ten I’d learned from some inaccurate article floating around the Internet. I asked him if he were busy next Tuesday. He laughed and said that he was booked for the next few weeks, so we scheduled the surgery for after the turn of the year. On January 19th I drove myself to Greenwich Hospital, registered, and had the TKA (total knee arthroplasty). Greenwich Hospital has the lowest rate of post-operative infection of all hospitals in the state of Connecticut. This is especially important for any kind of implant surgery: things get bleak if there is an infection involving an implant.

The path to the surgery took a good deal of time and effort. The hospital offered a two hour class on the day before Christmas to guide people facing a knee or hip replacement. After the class, I arranged with the local Red Cross to donate a pint of blood on Dec. 30th that the hospital would hold for the surgery. I started a course of exercise to strengthen the muscles around the knee. Getting the insurance company aligned took exceptional patience, but eventually they were able to provide some measure of support for my impending adventure. I was very fortunate to arrange post-operative recovery and rehabilitation through Waveney Care Center, very near my apartment.

Monday morning was cold. I was up well before dawn, as I had to drive to Greenwich and check in, bringing a bag with clothing and my laptop. The kind folks at the registration desk processed my arrival as courteously and efficiently as at a high-class hotel. I was brought to a pre-op room where I stowed my bags and changed into the hospital gown. I lay down on the hospital bed and a nurse started the IV. After I talked with the OR nurse, I was wheeled into the operating room. The surgery began shortly after 7:00 AM. I remember the bright lights and very cool air in the OR – the temperature suppresses infection, I was told. The anesthesiologist told me that I was about to go under and then I went out – in the middle of a word.

In the course of the operation the surgeon replaces the lower surface of the femur (thigh) joint, the upper surface of the tibia (shin) joint, and the back of the patella (kneecap). The operation could more accurately be called a knee resurfacing, but the common name is Total Knee Replacement or Total Knee Arthroscopy (TKA). As part of the operation, the surgeon removes the anterior cruciate ligament (ACL) since its attachment point is replaced by the mechanical bearing surface. Its function is replaced by elements of the implant. In my case, the surgeon selected the Zimmer Legacy System LPS-flex.

I have not posted my pre-op or post-op X-rays. I might at some future time. Suffice it to say that the surgery was necessary, as noted in this excerpt from the surgeon’s report:

“… There were advanced degenerative changes noted. There was bone exposed on both the lateral femoral condyle and lateral tibial plateau with grooving of the bone….”

I awoke in recovery three hours later, feeling disoriented but not that bad. A nurse helped me stand for a moment to show me that I could bear weight on my new knee, then guided me back into bed. The pain medicine seemed to not be working, which caused me a sense of panic, but the nurse was able to increase the dose a bit which helped somewhat. Some time later I noticed that my left leg was in a mechanical apparatus (continuous passive motion, or CPM, machine) that gently bent my left knee and then extended it, to keep it mobile while the wound healed. I used that machine for more than an hour each day, increasing the flex a few degrees at each session. The machine’s action was not painful: The discomfort from the surgery was not localized, and seeing my leg actually move was comforting. I did feel some discomfort when the physical therapist increased the range of motion.

By Thursday Jan. 22nd I was beginning to feel more alert, at least enough to complain that the pain medicine was clearly not working, and could they try something else? I was moved to Darvocet, then Vicodin (the drug of choice for my anti-hero Dr. Gregory House). Later I learned that the drugs were working just fine, the problem was that the operation is, frankly, painful. I remained somewhat light-headed and my blood pressure wasn’t coming up very rapidly, so the doctor decided to transfuse my pint of blood back. This helped: my vital signs improved. With the exception of the CPM sessions, my left leg was immobilized using a fabric-lined thigh-to-ankle sleeve, open along the front, strengthened with four or five very firm plastic strips, and secured with five Velcro bands. The first few days, it was hard to close – my leg was quite swollen. Once I got moving, and the swelling began to subside, it closed quite easily. I used the immobilizer into my first week at Waveny.

I brought my laptop with me. That Thursday I wrote my first post-op e-mail. It contained 24 words, and I got seven of them wrong. At the time I thought I was quite lucid. I later forwarded it to my friend and asked him if he could figure out what I might have meant. The pain-killers were stronger than I thought. I wonder what the hospital staff thought I was saying: I felt I was being very clear. That day, I achieved 76 degrees of flex, not quite the 80 degrees the physical therapist at Greenwich Hospital had hoped for, but close enough.

On Friday the 23rd I was helped into a wheelchair and driven from the hospital to Waveny in New Canaan. The driver was a Spanish immigrant, and we talked about Madrid and the opportunities that brought him to the US during the short ride. I got to Waveny in the early afternoon and they had already set a lunch aside for me. The desert was a home-made cream puff – it was so tasty! In fact, all the food was great. I hadn’t eaten so well since my last good vacation – and the meals were healthy and the portions just right. One of the physical therapists – Trisha – visited me that first afternoon. Her concern and sensitivity to my discomfort and uncertainty was profoundly comforting. On Saturday one of the occupational therapists – Gus – stopped by to see how I was doing. I said that I’d been working out with free weights at home and hadn’t had a chance to do anything for a while – could he get me a small weight I could use? He left for a moment and brought me a weight, then he sat alongside me and we talked while I did some upper body work, lying in my recuparatory bed, happy to feel that something was unchanged and more would be getting back on track. It is hard to express how emotionally moving it was, and still is in reflection, to feel that genuine compassion and care. I had not felt such a pervasive sense of concern for my well-being since I lived at home as a young boy.

Dr. Crowe said that I should remain in the immobilizer until I could do a straight leg lift. That took into the weekend, six or so days after surgery. Friday was discharge day from the hospital and admittance day at Waveny. Saturday they offered one hour of rehab, but I don’t recall doing much. Sunday was for rest, but I was able to get out of bed unassisted that evening.

On Monday Jan 26th, I began my regimen of two daily one-hour physical therapy sessions, the first at 9:00 AM, the second at 1:00 PM. My physical therapist, Wrenford, wore a shirt labeled “Physical Terrorist” asserting his determination and gusto. And so the work began. It seemed that every day I achieved another milestone. In a few days I started using a cane rather than the walker.

On the evening of Wednesday Jan 28th, after dinner, my daughters visited me with their Mom and stayed till 8:30 PM. When I walked with them to the exit, one remarked with surprise that my legs were straight! I had begun looking at my toes on my left foot anew. Even though my knee was still swollen, it was properly aligned over my ankle, just where it was supposed to be. For years I had grown used to my left foot being a bit further out to the side, and here it was right next to the right foot, where it belonged. I thought, “I love my new knee!”

Initially I took my meals in my room, watching TV or working on the computer. Encouraged by the nursing staff, I began walking to the cafeteria. During meals I got to know others who had knee or hip replacements. There were eight or nine of us, and we would usually sit together at two or three tables. One male patient was a schoolteacher from Westchester County. He was a gregarious NY sports fan. One female patient was joined at lunch by her husband, a cultured, charming gentleman from central Europe. They had raised six girls, and he had authored two books: one on gardening and one on the gardens of Moravia – with insightful commentary on the history and politics of the region.

I did not expect to get involved in occupational therapy, but the Waveny Care Center wants its patients to get along after returning home. The difference between OT and PT was put simply: PT is for the waist down and OT is from the waist up. I asked what the specific goals of OT were, and it turned out that I could meet them by using their kitchen. So I took the opportunity to make a batch of my Black Bean Soup (the recipe is posted elsewhere in this blog). One of the OTs bought the ingredients! I cooked it up and it was pretty good. I was able to use the stove, blender, tools and sink; reach items in cabinets overhead and load the dishwasher; and cook without getting off-balance or fumbling with the cane.

On Tuesday February 3rd, during the morning PT session, I was able to get 90 revolutions on the stationary bike, and - for the first time since the surgery - I walked without a cane. I was still apprehensive on the stairs, fearing that I might get my toe caught and trip. But each day I would do a little better, breaking down the motion of walking up a step into its components: minor weight shift (but don’t rock the hips), lift up from the knee, move the heel back then up, place the ball of the foot squarely on the next tread, shift weight (but don't rock the hip), lift with the quadriceps, bring the other leg to the next step, keeping the knee pointing forward. Repeat.

On Wednesday, I was able to achieve 86 degrees of flex in the knee. Stairs were challenging, I didn’t have the strength to climb normally but with the cane I could make my way up and down, one step at a time, haltingly. Thursday February 5th was my check-out from Waveny.

New Canaan has a program called GetAbout – residents can request transportation within the town by phoning in a few days in advance. They have a small bus and a van, and I used both. I had PT three times a week. On Tuesday the 10th, I got a ride with my ex to see our daughters’ choir concert in Weston. I was able to ride in the passenger seat both ways, and the girls were surprised and delighted to see me – and I was so proud of their performances! I used a cane to walk from the car to the auditorium, and got a spot on the end of a row so I could stretch out my leg. I never got too good with the cane. My goal was not to get good with the cane, but to get rid of the cane.

That weekend I picked up my car from Greenwich Hospital and drove home – freedom! My first stop was a car wash: Four weeks in the garage had left a remarkably thick layer of dust over the whole car, and someone had drawn a bit of art in the window-panes. I stopped at the grocery store and picked up a few things. Peapod was an enormous help during my immobile phase.

Over the next few sessions I documented my knee's progress on Facebook:

Friday, Feb 13th: 91 degrees.

Monday, Feb 16th: 99 degrees. My primary physical therapist, Jane, noticed that I was very tight on the outside of my left leg. Prior to the surgery I had become knock-kneed by over 10 degrees in my left leg. Now that my leg was straight, the muscles and tendons on the outside of my left leg were stretched taut. She recommended calf stretches and a particular massage across the tendons. It was acutely uncomfortable for about 55 seconds – and then it felt great. I started doing the massage at home. I was never able to get as much relief as that first time, but every time helped a bit more.

Wednesday, Feb 18th: 105 deg (but was only able to get to 104 on Friday Feb 20th).

I started walking up and down the stairs in my apartment, haltingly.

Tuesday, Feb 24th: 108 degrees.

Wednesday, Feb 25th: 110 degrees. This is an important milestone – once I was able to get 110 degrees I could move my foot enough to safely go up and down stairs.

On Tuesday, March 3, six weeks post-op, I had a follow-up visit with Dr Crowe. I had achieved 110 degrees of flex and in the office, with no warm-up, I was past 105 degrees. Dr. Crowe advised me that my goal was to reach 120 degrees, so I was well along. This was a significant relief – I had assumed that I was behind schedule on my way to 135 degrees. It turns out I was on schedule for 120, and all was well.

Friday, March 20: 118 degrees.

Over time the swelling in my left ankle diminished rapidly, while my calf took longer. I still have swelling around my knee, and I’m told that will persist into the summer. On Wednesday, March 25, I achieved 120 degrees of flex. The discomfort as of April 5 is minor, mostly associated with the swelling and weakness around the knee. I am able to go up and down stairs with just a minor, diminishing halt to the downstairs gate. The biggest problem I have in day-to-day life now is remembering to get up and walk a bit every twenty minutes or so. By the end of the day, my knee is sometimes a bit stiff. I’m told that by June I should be able to golf.

I graduated from physical therapy on Tuesday, March 31. Wrenford (while I was an in-patient), Jane (my lead physical therapist while I was an out-patient), Hillary and Trisha and the nursing, occupational therapy, and support staff at Waveny were profoundly helpful, supportive, understanding, and positive. You are all amazing people and make a superior team!

If you want to understand the surgical procedure involved in a total knee replacement, see this lecture by Dr. Seth Leopold of the University of Washington in which he discusses both the total knee and uni-compartmental knee surgery, and also discusses conventional hip and minimally invasive hip repair. His lecture includes a brief edited video showing elements of the procedure.

I met three others during my stint at Waveny who had both knees done simultaneously. I could not imagine that degree of discomfort – but they each said they wanted to get through it. One said that if she hadn’t done both at the same time, she probably wouldn’t have had the courage to get the second one done at all. On the other hand, a neighbor of mine had one knee done last fall and the other a few weeks before I had my surgery. He and I met at the pre-Christmas class at Greenwich Hospital. He’s doing very well.

If you want to talk about your TKA please post to this blog and I’d be happy to hear your story, or share more about mine. I’m done with the drugs, except for an occasional ibuprofen and some ice. I took a walk around the block this afternoon and it felt great! It’s been years since I was last able to do that. I'm looking forward to golfing this summer with my daughters and my doctors.