Friday, 3 October 2008

4th Time Lucky?

I have just got back home this afternoon after 2 and a half days on an orthopaedic ward and a 2 hour operation to fix the right hip joint that dislocated 3 weeks ago.

Both legs are the same length again and I have a new ball at the end of the femur which is the same size as the previous one and not larger as I was led to believe might be necessary.

My wife and I had arrived at 06:50 a.m. on Wednesday at the theatre admission unit at our local hospital and we were asked to find a seat in the rapidly filling small waiting room which had an overflow of seats along an adjoining corridor.

After about 90 minutes the Senior Registrar turned up and asked for a consent form which we discussed and I signed. He mentioned that he was not prepared for the amount of administration he would have to do when he started studying medicine and felt too much of his time was being spent chasing up and managing others.

I was told I would be third on his list. After about 12 patients (mostly with Orthopaedic problems but thankfully not all to be seen by the senior registrar who would operate on me!) had left, I eventually left the waiting room after a bay had been freed up for me to change into a theatre gown and be swabbed (for MRSA colonisation) etc. When I left the waiting area there was only one other patient still waiting. After this initial 2 hour wait I was somewhat rushed through. I was told that the 2nd patient had required some complex blood products before their operation could proceed so I was bumped up the list.

I was welcomed into Theatre reception by Sue who recognised me from previous visits with "Oh hello again!". Half an hour later I was on a trolley in the familiar anaesthetic room but this time not with the tall Hungarian anaesthetist who had been in charge for the previous 3 visits since March.

The anaesthetist before me asked for the records and was pointed to the 6 inches of notes lying under the trolley and exclaimed "Oh I see - one of those!" He scanned the first couple of pages and sought confirmation that I had not had a pre-op assessment and realised he would be "flying blind". After a cannula was inserted into the back of my right hand, blood pressure monitoring cuff attached to my left arm and heart rhythm contact tabs stuck to my body, the Senior Registrar arrived and requested muscle relaxant and left the anaesthetist to consider whether to administer 10 or 15 mg of morphine. He decided on the higher dosage with "Oh well lets party!"

The previous week the senior registrar had said that this operation would be a short one although if they needed to they would exchange the socket as well as the head of the femur so they needed my consent to a full exchange operation. He did not however envisage any problem manipulating the joint back into place once he had reasonable access. In the event this confidence was misplaced.

My next impression was waking up in the theatre recovery room (used for all surgery not just Orthopaedics) talking to 2 nurses a couple of hours later. Of course the operation had not taken that time as I would have taken some time to come round from the anesthetic.

In response to a question about what operation had been performed, I quickly brought the 2 nurses up to date - starting with the original revision nearly 5 years ago, before moving on to the intervening post operative sepsis, 2 stage revision and previous week's manipulation under anaesthetic. As I rattled off this series of interventions I felt increasingly emotional. This soon passed but when stated so quickly it really does seem a lot to have had to endure - not just personally but by my wife and children as well.

My wife later mentioned that a colleague with orthopaedic experience did say there was such a thing as "Orthopaedic depression". I'm not sure my 60 seconds of emotion qualify as depression but I was getting near to having to face the bleak reality of the 7 1/2 years (I had to wait for 3 years for the original revision) from the original referral to hopefully possessing a functioning and stable hip joint once again.

I remembered that "this too will pass" and moved on to being positive about the future and looking forward to getting back to where I was a few weeks ago and then continuing to progress from that point.

I was taken from the recovery room to a single room in an adjoining ward while a long term bed was found elsewhere. 4 hours later I was taken to another ward and onto a bed in a 6 bed bay - which unlike the previous week was a single sex unit.

I was written up for 2 intramuscular injections each of steroids and antibiotics. The antibiotics were to be given 8 hours and 16 hours after surgery. The surgery had finished before noon but it was about 2 a.m. the next morning that I was given what turned out to be a single anti biotic injection. (i.e. 14 hours post surgery) I had been given the single steroid boost, that I was to receive, 90 minutes earlier.

The reasons for the delay were that I had not been written up by a doctor and once I had been written up the only Nurse senior enough to administer such injections for all the orthopaedic wards had been too busy to do it any earlier. If I do contract post operative sepsis again following this latest operation I will be very annoyed particularly if it could be attributed to being denied adequate anti biotic cover because of low levels of competent staff being present.

The next day I was allowed to stand up and bear full weight through both hips. The physiotherapists were pleased that I was able to move out of bed easily and to walk with 2 elbow crutches. 5 minutes later after a brief demonstration of my abilities to walk around the ward I was "signed off". A little later an Occupational Therapist arrived to assess my need for aids etc which of course I still had from the 2 stage revision earlier in the year. She needed little convincing that I would be able to manage so she too "signed off". In theory I was free to go home provided an X-Ray was satisfactory and the incision was clean.

The x-ray was ordered for the middle of the next morning and once seen by the house officer all that needed to be in place for my early discharge was the pharmacy to provide a supply of drugs and for some paperwork to be completed to let my GP know what had happened.

While waiting for lunch (and the drugs to arrive) a patient opposite - who had returned from theatre about 18 hours previously - was beginning to come around and want a urine bottle. Unfortunately his nurse call button and handset were not working. He raised a weak right arm and I went over to see what he wanted. I pressed my nurse call button twice (the first time - a nurse had come to the bed and acknowledged his need but became distracted en-route and never returned). I tried again and in all 10 minutes had elapsed before I decided I must find a nurse somewhere on the ward. As this was around lunch time the nurses were mainly involved in sorting out patient meals. One nurse responded by saying she could not help because it would mean changing out of the apron she was wearing to serve food, that she would then need to wash her hands and put on a different apron to provide the urine bottle and then wash her hands and change back again to continue serving food.

I noticed that a ward round had just started so interrupted it, with apologies, and explained to the senior nurse that Mohammed had been waiting 10 minutes for a urine bottle and was looking increasingly agitated. She excused herself and sorted it out straight away. Another example of inadequate staffing levels to cope with the demands on nursing staff which can work to the detriment of basic patient care.

As it happened the ward round I had disrupted was that being undertaken by the team that I was under. The consultant seemed pleased to see me walking around the ward and we exchanged a few comments. He had been present at the operation and the senior registrar explained that he had to call in a "muscle man" to help because they had difficulty manoeuvring the joint back into place. I thought he meant someone specialised in tissue damage and muscle reconstruction but what he really meant was that they had to call on the consultant to help provide more "weight in the scrum".

He then went on to say they had thought the consultant would provide the extra "beef" required but it turned out he was a lamb. They concurred that it had been a real effort to stretch the muscles etc sufficiently to relocate the joint and once back in place they could not dislocate it again which they try to do to work out how it might have happened so they can advise what action to take to reduce the chance of it happening again. They have put the dislocation down to scar tissue breaking down and changing the stresses and strains around the joint.

As I stood before them I noticed the Senior Registrar look down at my right foot which was pointing out about by only 5 degrees and not the 30 or so I had reported before the dislocation. I saw him glance at the consultant and (try to draw his attention to this). I wondered therefore if they might have taken this observation on board when they came to relocate the joint with a view to a straighter alignment. To my mind if I notice that the right foot again points out by a significant degree I will probably take this as an early warning that the joint is precariously located in the socket.

After some advise about how best to sit down, to take it easy and if I ever notice a leg length difference again not to improvise with a lift inside my shoe, the consultant said that it continued to surprise him that patients like me ( who have had repeated surgery to the same joint) experience no pain when the joint dislocates. Him and me both!

As soon as one morning after my discharge I have abandoned the elbow crutches for 2 walking sticks and can even manage with just one. I feel that my right leg is my own again and that I am increasingly confident when taking weight through it and realise that apart from taking things easy while the muscle and tendons in my right leg recover, I am now well on the way to my goal of walking - with or without a stick - by the end of the year so I feel back on track once again.

So hopefully this will turn out to be a case of 4th time lucky!