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Saturday, December 03, 2016

EVOLUTION OF SURGERY AND ANAESTHESIA

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Greetings and Salutations to All my Kith and Kin and All the Ships in Outer Space:
 
This is an article I submitted for publication in, "JAMA", the official journal of the American Medical Association.
 
Although it was not published, I'm flattered that it was accepted for their review.
 


"AN ELDERLY BABY BOOMER'S PERSONAL
EXPERIENCES IN THE EVOLUTION OF SURGERY AND ANAESTHESIA TECHNIQUES"

By: JOHN ROBERT MALLERNEE
Thursday 16 October 2014
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PERSONAL BACKGROUND:
 

I was born David Roy Trueblood, at 2200 Hours, minus 09 Minutes, on Monday 28 January 1946, during a poker game in a tent beside the railroad tracks in Ellensburg, Kittitas County, Washington, delivered by Burton Alexander Foote, M.D., to Roy Lane Trueblood and Hazel Irene Albertson.

In that family, there were five (05) sisters older than me, two (02) brothers younger than me, and two (02) younger half-sisters.

According to official court documents in Decatur, Macon County, Illinois, all but the youngest boy and the two (02) half-sisters were abandoned by our biological parents, resulting in each of us then being adopted by different families, to grow up separated from each other, with different identities and heritages.

With my new identity of John Robert Mallernee, I was adopted and raised by Master Sergeant William Vincent Mallernee, United States Army, and Virginia Lee Mapes, with three (02) younger sisters, plus two (02) younger sisters who did not survive beyond infancy.

During my teenage years, with my parents no longer able to control me, the Juvenile Court issued a court order which involuntarily committed me to a state psychiatric hospital, initially at Big Spring, Texas, and again at Dorothea Dix Hospital in Raleigh, Wake County, North Carolina.

Now, we're ready to begin my reminisces of the evolution of surgery and anaesthesia techniques, as documented in my own personal experiences.
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FIRST SURGERY - Tonsillectomy/Adenoidectomy:

I do not remember exactly how old we were (maybe I was nine years old?), but I and my two (02) younger sisters (the youngest had not yet been born) were students at Spring Lake School (since renamed Lillian Black School - - - she taught me in Fourth Grade) in Spring Lake, Cumberland County, North Carolina, where Daddy, a career Master Sergeant in the United States Army, was stationed at Fort Bragg.

The three (03) of us were hospitalized at Fort Bragg away back in the days when Army hospitals were composed of sprawling, confusing, single-level mazes of VERY lengthy yellow-painted wooden corridors, years and years before the more modern multi-storied concrete and steel Army Medical Centers would eventually be constructed.

My very first impression was to be disgusted, insulted, humiliated, and angry because I was a boy being forced to lie down in a BABY bed!

For the surgery, I was put to sleep with Ether (which smells sickeningly HORRIBLE!), administered by a specially shaped gauze and steel cup placed over the face, with drops of Ether carefully poured over the gauze, with isolated drops occasionally impacting on my facial skin, as I counted aloud backwards from one hundred.

I know what it looked like, because in the newspaper comic strip, "JOE PALOOKA", that exact scenario was portrayed when boxing promoter, Knobby Walsh, was being treated for his heart attack.

Unconscious, I dreamed a vividly frightening nightmare of a HUGE green colored letter, "F", in the midst of green colored circles, on a pitch black background, all of it rapidly spinning round and round, with the giant letter, "F", getting closer and closer and closer, until finally colliding with my - - - ! ! !

 
I was awake, and in a nauseous agony of indescribably painful coughing and retching, spitting up and spewing panfuls of a dark colored fluid (a blend of blood and ether?).

As I lay in bed, unable to speak, Daddy came to visit me, bringing me two (02) presents, a book, "THE ADVENTURES OF SPIN AND MARTY", and another book, "TARZAN AND THE LOST SAFARI".

I'm quite certain that my two (02) sisters also received presents, although I don't know what the presents were, and Mama may have been there to console them, but I can't really remember it.

I do remember that as we drove home from the hospital, Mama and Daddy stopped at the grocery store to buy lots of Ginger Ale, and plenty of ice cream, Jello, popsicles, et cetera.

And, of course, at school, all of us kids would excitingly relate our experiences, and compare notes, rather obviously scaring the pure living Hell out of all the other kids who hadn't yet had their tonsils removed, for tonsillectomies were pretty much of a common rite of passage for all kids in elementary school.
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SECOND SURGERY - Mastoidectomy:


I mentioned previously that I had been involuntarily committed by an order of the Juvenile Court to YEARS of unbelievable horror in state mental hospitals.

That, in itself, is a pretty fantastic tale, but one I will not go into at this time.

However, while locked up in the state's insane asylum at Dorothea Dix Hospital in Raleigh, Wake County, North Carolina, I was suddenly transferred from the long term psychiatric unit to the surgical unit, having been told that I was very sick and needed immediate surgery to save my life.

Odd, because I never felt sick.

On the day of the surgery, I was wheeled into the scary looking operating theatre, and told to lie down on the table.

There was a large, shiny metal plate, with wires connected to it, which I was to lay my bare bottom on.

Upon seeing this, my very first impression was dread of electrocution, a fear even more enhanced due to having previously been forced to endure the repeated horrors of multiple electric shock treatments!

But, they calmed and reassured me, and I climbed onto the table, with my bare skin against that metal plate, although I was still terrified and traumatized.

There were two (02) objectives in this surgery.

First, the left mastoid bone needed to be removed.

Second, a graft was to be taken from a blood vessel on my left temple, and used to repair my perforated left eardrum.

I was given an injection of Sodium Amytal (?), and once unconscious, would be given Fluorine (?) gas to keep me asleep.

Although, a successful surgery, not everything went as planned.

I don't remember what, if anything, I dreamed about.

When I woke up, there was indeed, some nausea and vomiting, almost certainly an expected side effect of inhaling gas, but it was relatively minor, and nothing at all like the agony of Ether's after effects following a tonsillectomy.

Anyway, I was told that the incision on my left temple was far larger than expected, because when the scalpel blade touched my skin, I suddenly leapt up, and began fighting, and had to be physically restrained before surgery could continue.

The time spent recuperating was at least a couple of three weeks or more, but I enjoyed it.

After being forcibly incarcerated with and preyed upon by violent, sadomasochistic socio-psychopaths, with no hope of escape, twenty-four hours a day, seven days a week, and equally terrorized, abused, and preyed upon by the very staff who were supposed to be protecting me, it was pure HEAVEN being on a real, actual medical hospital ward, free from any physical danger, and able to enjoy looking at the pretty, young nurses.
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THIRD SURGERY - Tympanoplasty:


Miracles of miracles, in spite of my unusual background normally precluding any such opportunity, I was able to become a regular soldier in the United States Army!

While stationed in Germany at Spangdahlem Air Force Base, my left eardrum was once again perforated.

Subsequently, I spent two (02) consecutive years in the old Republic of Viet Nam, as a soldier in the United States Army with a perforated eardrum, having been informed that there existed no facilities for repairing it.

Time passed, as did assignments, and eventually, I was stationed at Camp Long in Won Ju, Republic of Korea.

During that time, the doctors determined that my left eardrum could be surgically repaired.

It was to be done at the 121st Evacuation Hospital at Yong San Army Garrison in Seoul, Republic of Korea.

A Korean surgeon in the United States Army, Dr. Kim, performed the surgery, basically repeating what the surgeons in North Carolina had done many years earlier, but with a uniquely gruesome twist.

He would be drilling directly into bone tissue, with no way to locally anaesthesize the pain, AND, general anaesthesia was not possible, because he needed me to be awake, alert, and conversant throughout the surgery.

So, as he explained it to me, I would feel every bit of the pain, but - - - ,

With the drugs he would be administering, I wouldn't care!

He was right!

I felt every bit of everything that was happening, and was alert enough to answer his questions during various phases of the surgery, but the pain didn't bother me.

After completion of the surgery, I slept for three (03) solid days and nights, non stop, straight through.

When I finally woke up, during my recuperation, they gave me Demerol for pain, and boy, oh boy, do I love that stuff!

No wonder people become desperate drug addicts and rob pharmacies!

That there Demerol is really some top notch GOOOOOD stuff!

In the Nineteen Seventies, folks everywhere enjoyed watching the wildly popular television series, "M*A*S*H", based on the novel and Hollywood motion picture, "M*A*S*H".

In virtually every episode of that, "M*A*S*H", television series, references would be made to, "the 121st Evac in Seoul".

While the 4077th M.A.S.H. was a fictitious military unit (albeit based upon an actual unit with a different numerical designation), the 121st Evac, in Seoul, was a real unit, and I love telling "M*A*S*H" aficionados that, "they operated on me at the 121st Evac, in Seoul".
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FOURTH SURGERY - Catheterization and Drug Eluting Stents:

In the Autumn of 2013, those of us residing at the Armed Forces Retirement Home in Gulfport, Mississippi who are not career military retirees, were officially declared Department of Defense designees, authorizing us to now receive medical treatment from the 81st Medical Group at Keesler Air Force Base, an option that offers a much superior alternative to the Gulf Coast Veterans Health Care System in Biloxi, Mississippi.

Did you know that, statistically, in over half of all heart attacks, the ONLY symptom is sudden death?

To complicate things further, heart attack symptoms vary for each individual.

One very common symptom in virtually ALL heart attacks is - - - "DENIAL"!

The person suffering the heart attack delays seeking emergency response because they don't want to accept the awful truth that they are in the process of dying right NOW, this very minute!

I wanted to play Santa Claus on Christmas Eve.

A few days earlier, even though I had very little money, I'd gone downstairs to the Navy Exchange mini-market located on the Main Floor of our Armed Forces Retirement Home, where I purchased five (05) gift wrapped boxes of assorted chocolates, two (02) tins of Christmas cookies, and six (06) very large Hershey's Kisses chocolate Christmas candies, which were the gifts I planned to stealthily and secretly distribute to - - - WHO?

This is what I had successfully done the previous year, and nobody caught me, or knew it was me, so I wanted to do it again for Christmas of 2013.

Well, around 2300 Hours, plus 30 Minutes on Christmas Eve of 2013, I woke up from my brief nap, and sat on the edge of my bunk.

My head began woozily swimming, and I felt a sensation of something within my body suddenly falling from my brain to the soles of my feet.

What the heck was that sensation?

Immediately, I knew I was in big trouble, and wouldn't be able to play Santa Claus.

So, I laid back down to continue my nap.

That's when the really bad toothache began deep within the gums and jaw on the right side of my face.

Once again, I sat up on the edge of my bunk, and rummaged through the drawer of the nightstand, searching for toothache medicine.

At some point, my chest began hurting, and I thought it might be heartburn.

So, after walking around in my quarters for several minutes, hoping this suspected mere heartburn symptom would ease off and go away, I laid back down on my bunk, and then felt the pain in my back, located at the same height as the pain in my chest.

One way to tell if it's merely heartburn or a heart attack is the length of time that the chest pain lasts.

If the pain lasts longer than a few minutes, call the ambulance, lest someone else should have to contact the police, the coroner, and the funeral home.

Remember, "DENIAL", is the most common symptom in ALL heart attacks!

Well, I pulled on my clothes and slippers, and rather than going downstairs to our medical clinic, I pulled the emergency cord located by my bunk.

Then, while sitting on the sofa awaiting their response, I touched my forehead with my hand, and felt the sweaty clamminess, which, when combined with the other symptoms, was the sure giveaway that THIS was the real thing!

The night nurses came to my room and, while examining me, called for an ambulance.

While waiting for the American Medical Response ambulance to arrive, they gave me two (02) aspirins.

Folks, if you've ever seen that television commercial for Bayer Aspirin, which recommends taking aspirin at the first sign of a heart attack - - - ,

Well, it is the absolute gospel TRUTH ! ! !

Taking that aspirin made all the difference, for by the time the American Medical Response ambulance crew arrived, the pain began slightly easing, and when we reached the Emergency Room of the 81st Medical Group at Keesler Air Force Base, the pain had completely disappeared.

So, instead of being admitted to the Intensive Care Unit, they put me in a room of the Medical Nursing Unit on the Third Floor, while they drew blood samples and interviewed me.

When they learned the results of the blood tests, they had the indisputable proof that I indeed had suffered a heart attack, resulting in serious damage to the heart.

Thus, I was immediately transferred downstairs to the Intensive Care Unit.

While lying there, I had visitors, Brother Jerry Guynn and Brother Bill Sowers, my assigned Home Teachers from the Gulfport Ward of The Church of JESUS CHRIST of Latter-day Saints (i.e., the "Mormon" church).

Brother Sowers anointed my head with consecrated oil, and with their hands upon my head, Brother Guynn pronounced a Priesthood blessing.

The following day, which was the day after Christmas, I was wheeled into the Cardiac Catheterization Room.

The gal who was about to begin the procedure warned that it would feel like a wasp stung me, and that sensation would last about twenty (20) seconds.

However, I felt NO pain or discomfort at all.

During the cardiac catheterization procedure, the patient is required to be awake, in order to answer questions.

But, the sedative drug that is being administered intravenously, has a side effect of erasing all memory of what's going on.

A little while ago, one of the guys told me it is the very same chemical that's better known as the notoriously illegal "Date Rape Drug".

So, the only thing I remember is the very beginning of the cardiac catheterization process, which went perfectly, as four (04) drug eluting stents were implanted in the arteries surrounding my heart.

Unfortunately, what happened after I was returned to Intensive Care WAS a nightmare!

For some reason, they couldn't get the bleeding to stop at the point of my groin where the catheter had been inserted.

So, as they continually tried everything they could think of, I was forced to lie on my back, absolutely still, and therefore unable to relax and get any sleep, as they tried femoral tourniquet after femoral tourniquet, and even bandaging with a sandbag weight.

Nothing seemed to work, and everybody was worried.

Then came the worst of all, when they decided to take turns putting direct pressure on the wound, pressing down hard with two (02) fingers.

Oh, what unbearable pain I then had to endure!

It went on all afternoon, all night long, and on into the next morning.

Finally, they found the solution, which was to administer injections of two (02) drugs, Lidocaine and Epinephrine, at the wound site, and then place an occlusive bandage on it.

Oooooh, what a relief!

They gave me Percocet tablets for pain, and Melatonin to help me sleep, and then transferred me to the Surgical Nursing Unit on the Fourth Floor.

The private room was really great, for it had a large screen television and a beautiful view of the Back Bay in Biloxi, Mississippi.

For a while, I had to have lots of help doing anything, because I was so dizzy and faint, due to hypotension.

But, Saturday 28 December 2013, only FOUR (04) DAYS after my heart attack, was the big day, for I was able to return to my comfortably furnished private quarters here on the Seventh Floor of the Armed Forces Retirement Home in Gulfport, Mississippi.

I consider this event a real blessing, for now that I know what MY heart attack symptoms are, my chances of surviving any future subsequent heart attacks are greatly increased.

The very BEST feature of being hospitalized at the 81st Medical Group on Keesler Air Force Base was being surrounded and attended to by all those lovely young girls!

All that eye candy is a lonely old geezer's fantasy!

Probably due to the mandated constraints imposed by "political correctness", it appears that females now far outnumber males in the United States Air Force, as it is certainly the rather obvious case in the 81st Medical Group hospital.

But, so what?

I was plumb HAPPY ! ! !

Girls! Girls! GIRLS ! ! !

And each and every one of them young and, oh, so pretty, pretty, pretty!

All in all, based entirely on my own personal experience and observation, hospitalization and/or medical care at the 81st Medical Group on Keesler Air Force Base is undoubtedly far, FAR superior to what I've encountered at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi.

I've heard the same opinion expressed by other military veterans and/or fellow residents here at the Armed Forces Retirement Home in Gulfport, Mississippi.
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FIFTH SURGERY - C3-C4 Anterior Cervical Fusion with PEEK Cage

Some time back, for whatever reason I can't even remember, the psychologist at the Armed Forces Retirement Home (who is no longer employed here) administered a battery of intelligence tests to determine how my brain was functioning, and why.

I reckon it may be because I've pretty much always been the sort of guy who fits like a proverbial square peg in a round hole.

Anyway, right at the moment his contract expired and was not renewed, he was generous enough to show the test results, even though he was actually there on his own time, with no contract and no pay.

At one end of the spectrum, my IQ is at least 130 or more, and at the other end of the spectrum, my IQ is at least 130 or more.

But, right in the middle, there is a part of my brain that isn't functioning at all, not even at the level of "FORREST GUMP".

So, since I'd had a heart attack, it was a good indication that I might also have suffered a stroke, leaving me with significant brain damage.

An immediate MRI scan of my brain was recommended and so ordered.

At this same time, I'd gone to see the staff physician at the Armed Forces Retirement Home, Matthew Carlson, M.D., complaining that my hand hurt whenever I was operating my computer, and put my hand on my mouse.

I suspected Carpal Tunnel Syndrome, but Dr. Carlson said I wasn't exhibiting those symptoms.

So, while ordering the MRI of my brain, he further ordered an MRI scan of my neck.

Ain't it plumb wonderful and downright miraculous that he thought to do so?

Had he not done it, I might be dead right now, for the neurosurgeon, Miguel Angel Melgar, M.D., Ph.D., F.A.A.N.S., F.A.C.S., stated I was within a fraction of a hair of becoming paralyzed from the neck down.

He said that all I had to do was trip and fall down just one time, and that would have been the end of me right there on the spot.

Dr. Melgar repeated over and over again that it was purely miraculous that the correct diagnosis was accidentally stumbled across just in the nick of time.

Oh, by the way, as much as I can determine, the MRI scan of my brain did not indicate any damage.

Soooooo - - - ,

Maybe I just plain ol' ain't like all those other ordinary "normal" folks, huh?

As for the surgery on my Cervical Spine?

It was scheduled twice, and postponed twice, first because they needed to have my prescription medications completely flushed out of my system, and then, at the very last minute, when it was discovered that I had a urinary infection requiring a couple of weeks on antibiotics.

Finally came the big day when, at long last, the mad doctor would cut my throat!

Outside of the Operating Theatre, I lay on a bed or gurney (?), while a Nurse Anaesthesiologist and someone sitting at a desk were doing whatever they do.

Since I was still conscious, and it's now down to the last minute, I figure it's time for a bit of fun.

"Uh, Nurse, I've got a confession to make.

When I was listing all of my medications, I forgot to mention that I'm a heroine addict."

"Oh, please don't tell us that!

Not NOW!"

"Ah, yes, I'm a heroine addict - - - ,

I like girls!"

"Also, I use Coke.

I prefer Pepsi-Cola, but I do use Coke."

"You know, here I am at this hospital, with Medicare paying thousands and thousands of dollars, just so the Country's top neurosurgeon can - - - ,

Cut my throat!

If only I'd gone to Syria - - - ,
ISIS would have gladly cut my throat for free!"

So, seriously, how do you think my surgery went?

I don't remember going to sleep.

I don't remember waking up.

There was no pain, no nausea, no vomiting, absolutely NO unpleasant after effects at all!

The only glitch was edema in my throat due to the trauma of surgery, situated between the cervical spine and the trachea and esophagus, which was interfering with the proper closure of the epiglottis, which created a danger of strangulation and/or aspiration pneumonia.

As a result, I went the next several days with no food or water allowed in my mouth.

It was apparently serious enough that Dr. Melgar requested the telephone number so he could personally call my next of kin at that very moment.

Because the edema was taking so long to recede, Dr. Melgar was ready to insert a feeding tube down my nose, which would be followed up a few days later with surgery to cut a feeding hole directly into my stomach.

Boy, I was horrified!

I was working around the clock, constantly pushing myself, learning all over again techniques for swallowing without choking, and getting my bowels and bladder to function dependably.

But, the timing of this surgical procedure couldn't be better!

After all, here I am with this bodaciously looking bandage and fresh cut throat, walking around looking like this, just in time for - - - ,

HALLOWEEN ! ! !

Ain't that so super duper neat?

Do you know who it is whose medical specialty it is to teach you how to properly swallow your food without choking?

A SPEECH THERAPIST!

Can you believe it?

Another interesting aspect of my post operative hospital care was - - - ,

Major construction and renovations being done on the Post Operative Ward at the very same time that Post Operative patients are on that ward attempting to recuperate!

So, I'm back at the Armed Forces Retirement Home, where nursing staff improperly changed the surgical dressings, resulting in slight inflammation at the incision site.

If all had went as planned, the bandages should have been removed yesterday when I was getting my follow-up exam at the hospital.

As it is, I now have to start taking antibiotics (IF I can even get the prescriptions filled - - - again, our own AFRH nursing staff), and I have a brand new surgical dressing on the incision which is NOT to be removed at all.

I must continue seeing Dr. Melgar weekly, until further notice, and I am to stop wearing the Aspen Collar, as it is irritating the wound.

I mustn't shower, but only give myself careful sponge baths.

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SIXTH SURGERY - Colonoscopy 

Some say a colonoscopy is not really surgery, but some say it is, since it requires anaesthesia, and the procedure is done inside of the body.

My colonoscopy was performed at Ashley Regional Medical Center in Vernal, Utah.

The only real problem with a colonoscopy is preparation, because the effect of all those powerful laxatives can get really messy and inconvenient, especially during the time between taking the laxatives and the time it takes to get to the hospital.

I think the laxatives really should be administered in the hospital, with the patient being hospitalized.

The anaesthesia that was administered permitted me to converse with the surgeon, while simultaneously erasing my memory, and thus, there were no side effects following the anaesthesia.

Having the colonoscopy GREATLY improved my ability to evacuate my bowels, so it's definitely a procedure that I'd very highly recommend for EVERYONE!
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SEVENTH SURGERY - Fusion of L-4 and L-5 of Lumbar Spine

On Wednesday 12 October 2016, a day which was both Columbus Day and Yom Kippur, I underwent surgery at the University of Utah Medical Center in Salt Lake City, Utah, to fuse L-4 and L-5 of my lumbar spinal column, performed by Brandon Douglas Lawrence, M.D., of the University of Utah Orthopaedic Center.

The only noticeable side effect from the anaesthesia, which was administered with no discomfort, was momentary confusion upon regaining consciousness.

Due to pain and exhaustion, I refused to eat anything, but surprisingly, I was able to walk a short distance, across the hall and back.

They gave me plenty of drugs to control the pain, and a few days after the surgery, I was transferred to the Holladay Healthcare Center in Holladay, Utah, to begin physical rehabilitation.

Enduring the physical rehabilitation was worse than the surgery!

Finally, I'm now back home in my apartment, but still feeling some pain, and having some difficulty staying on my feet, having fallen several times already.

The Department of Veterans Affairs has issued me a Pride Mobility Victory 9 powered mobility scooter (with four wheels instead of three, plus a headrest on the seat), plus installing a lift for it on the trailer hitch of my 2004 Ford F-150XLT four wheel drive pickup truck.

Pride Mobility Victory 9
The Department of Veterans Affairs hired a Community Health Nurse to visit me one day each week to supervise my medication, as I have a BUNCH of prescriptions!

Also, the Department of Veterans Affairs has hired a Certified Nurses Assistant to visit me each week, to make sure my apartment is clean and livable.

At the moment, as I type this, my knees are not supporting me, so I had great difficulty photographing that powered mobility scooter.
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EIGHTH SURGERY: Fusion of C-2 to T-1 of Cervical Spine

On Wednesday 18 September 2019, I underwent six (06) hours of emergency surgery by Robert J. Owen, M.D., at the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah to fuse C-2 to T-1 of my Cervical Spine.

When the anaesthesia was being administered, the nurse anaesthetist told me to breathe deeply and dream of pink butterflies, to which I responded that I was a guy, and since guys dream about girls, I would dream about her.

There was a split second of blackness, and once again the nurse anaesthetist was urging me to take deep breaths, as the surgery was over, with no unpleasant side effects from the anaesthesia.

Following a three-week convalescence at the Holladay Health Care Center in Salt Lake City, Utah, I am once again back in my little one-bedroom apartment in Vernal, Utah, sitting at my computer, but heavily sedated with opiates, and compelled to wear a neck brace for the next couple of months.
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Anyway, Folks, there you have it.

Those are my memories of my own personal past surgeries, indicating the progression and development of surgical and anaesthetic techniques during my lifetime.


Thank you.

John Robert Mallernee 
1800 Beach Drive, Unit 311 

POST SCRIPT:

Due to a racial confrontation with a nurse who refused to change my bandage, followed by my publicized accusations of both, medical incompetence and an overt anti-Caucasian racial bias (which I continue to maintain, without apology), I was summarily evicted from the Armed Forces Retirement Home in Gulfport, Mississippi, on Friday 05 December 2014, forfeiting much of my personal possessions, and compelled to spend the Winter sleeping in the cargo bed of my pickup truck.

Having survived a VERY cooooold winter (brrrrrr!), I now reside at Ashley Valley Shadows in Vernal, Utah.

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