Infection Control - Rhetoric & Reality

I reproduce below the content of an email I sent a few days ago to the Coordinator for Infection Control for our local acute hospitals Foundation Trust. The message compares the Trust's infection control policy with recent personal experience after being told I had tested positive for MRSA.

The content is fairly self explanatory and relates some of my previous experience and interest in this area. The term nosocomial infection basically means the entire range of hospital acquired infections and while incorporating the headline problems of MRSA and C. Difficile, includes all avoidable infections contracted while in hospital. A large proportion of the community have MRSA colonisation in the nose and/or groin areas. It does no harm provided they are not immuno supressed and avoid transferring the bugs to an open wound. If it then becomes established in the blood stream it is called a bacteremia. It is the level of bacteremia's that hospitals monitor to demonstrate the progress they are making in hitting government targets to reduce MRSA.

I remain concerned at the gap between rhetoric and reality and wish to assist local management to avoid becoming complacent and overly self congratulatory.

I have changed names to "protect the guilty" - otherwise the email is unedited. By the way the doctor charged with responsibility for co-ordination of infection control policy is known as the DIPC which is pronounced by those in the know as "dipsy" - what a great example of a self deprecating acronym!

Dr B.......,

BACKGROUND:

We met on a couple of occasions in the past when I was one of the original Patient Governors of the Foundation Trust.

I expressed a particular interest in nosocomial monitoring arrangements and we discussed how such a system might be designed once test results could be obtained on a more regular basis from existing laboratory systems. I had experience of designing a graphical module of an Executive Information System for 2 hospitals in Saudi Arabia which provided both comparative and chronological reports and offered to assist if that would be useful. You were at the time preparing a proposal to the Trust Board for the establishment of teams of ward based co-ordinators.

Adequate control of hospital acquired infections was the first of 4 reasons I put forward in my election statement for wanting to be a Patient Governor. At the first meeting with the Chief Nurse, after being elected, I asked whether any system existed to regularly monitor nosocomial infection rates with a view to the early identification of potential hot spots. I was told, erroneously as it turned out, that a system , along the lines that I had described setting up in Saudi Arabia, was then in existence. I was content with this response and concentrated instead on other matters that I had identified in my election statement.

Soon after election as a Governor I developed post operative infection in my right thigh which required an operation to clean out and resulted in an exacerbation of renal impairment requiring 2 weeks on dialysis and about 4 months recuperation at home to have the strength to get out and about outside of the house. 4 years on and after significant tissue and bone loss due to infection a 2 stage hip revision has been carried out. I was discharged from ........ ............. ward 2 days ago on Tuesday 22nd July.

Prior to admission I had been swabbed for MRSA colonisation in nose and groin on several occasions and had always been pleased when the results were "negative" (I have used quotes to signify that I understand that a negative result only means an undetectable level of MRSA)

In accordance with current policy I was swabbed for MRSA on admission for the 2nd stage operation on 16th July and again on return to the ward from POSU on Friday 18th July. I was notified that I had tested positive on Saturday morning 19th July and would be moved to a side ward once one became available. The nursing staff had I think previously determined that I had some insight into the implications of this and were in any event busy with other things so I had no further information or guidance about what actions I might need to take.

I want now to describe as factually as possible my experiences and leave you to compare how far this accords with current guidance. I would then like to reflect on this and identify a number of areas where I think current practice needs to be reinforced by further training; where current information for patients needs to be reviewed to improve the likelihood of success in treating colonisations and finally to seek clarification on a number of matters that I remain unclear about.

I am doing because I wish contribute in a constructive manner to something I have been concerned about for 20 years and in no way desire what I have to say to be treated as a complaint. Unfortunately complaint handling is so defensive within the Trust that it only serves to frustrate and deny opportunities for organisational learning - and that is the last thing I wish to see.

I do hope that you understand the background to my contacting you and will wish to continue to read what I have to say and recognise that I do this in a spirit of continuing process improvement rather than of criticism.

SPECIFIC EXPERIENCE

(1) On Saturday morning 19th July I was told - in a whisper so that other patients could not hear - that I had MRSA in my nose - not that I had tested positive for colonisation only. From previous knowledge I knew I did not necessarily have a bacteremia and that what I had could be treated. I indicated to the nurse concerned that I understood this could be treated and was told that was so and told that I would be moved to a side room once one became available.

(2) Shortly after this the physiotherapist and assistant came to help me get out of bed and bear weight for the first time post operatively. The central and arterial lines had been removed the day before in POSU and I had only just had the catheter and epidural removed. As a result although a cannula was still in place in my arm it was no longer attached to any line. I asked the Physio if she had been notified of my changed infectious status to which she sought clarification. I said I had tested positive for MRSA colonisation in the nose. She confirmed she had not been told, thanked me and disappeared along with her colleague to acquire protective apron and gloves. A zimmer frame was borrowed from another patient, my progress monitored and while I was transferring to a relocated and higher than average bedside chair, the zimmer frame handle was wiped before the zimmer frame was returned to the patient from whom it had been borrowed.

(3) I was removed to a side room later in the afternoon on Saturday 19th July. I still had received no further guidance about what I could and could not do. I was provided with a plastic wallet containing some wet wipes and told these were for my sole use and not to be used by any other patient.

(4) On Sunday 20th July in the morning after the drug round a nurse left a carton containing the nasal ointment and a 500 ml container of Hibiscrub and said she would return shortly to help me to wash. I understood from her that I had to apply the ointment 3 times a day to each nostril - no cotton buds were provided so I assumed I had to use a little finger instead. When the time came for a wash a bowl placed in a plastic bag was filled with hot water and a capful of Hibiscrub was poured into the bowl. I was told that I had to wash my face and upper body and wash my hair with this. I used my own flannel but on her return the nurse provided me with some disposable paper flannels and asked me to wet one to "wash" my hair with. I understood from her I would need to repeat the hair wash on day 4 of the treatment. The nurse used a flannel to wash my back and when I had finished drying myself with my own towel emptied the bowl and left. Later that day I repeated the use of the nasal ointment a further 2 times.

(5) On Monday 21st July I had read the patient information that came with the nasal ointment and noted that I should ensure I used hand gel or similar to wash the nozzle of the ointment tube to avoid recolonisation. The Control Of Infection Co-ordinator for the ward unit called by in the morning to introduce herself and to leave a newly printed patient information leaflet. From discussion with her I understood that I should not use my own flannel, should have a change of underwear and nightwear each day again to avoid recolonisation and should have been provided with some cotton buds to apply the nasal ointment. Shortly after this a different nurse appeared with an uncovered but filled bowl of hot water for me to wash with. She also poured a capful of hibiscrub into the bowl. This time I used the disposable flannels provided. I continued to apply the nasal ointment throughout the day. I read the patient information leaflet and realised that I should have been provided with a clean towel each day. I noted that the ward staff did dispose of the bedding in a plastic bag each day in accordance with the guidance in the patient information leaflet.

(6) On Tuesday 22nd July morning a Health Care Assistant came to help me wash. She filled a bowl covered in a plastic bag with hot water and asked me I if I had my own soap and flannel . I assumed from this that she did not fully comprehend that I had to wash using the hibiscrub and disposable flannels. I suggested to her that I would need a clean towel which she was happy to provide. I was discharged home around 2:00 p.m. and understood that I should continue the treatment until today 24th July and wait for 3 clear nasal swabs before being declared "free" of colonisation by MRSA.

(7) On Wednesday 23rd July my first morning wash at home meant that I read the instructions more carefully and realised that the HIbiscrub should be applied neat and not diluted and should be left for about 4 minutes to dry before being rinsed off with a disposable flannel before drying off with a towel used the one time only. I also "washed" my hair with an undiluted quantity of hibiscrub. In the absence of cotton buds I continued to apply the nasal ointment by finger and to clean the nozzle with gel that I had brought back with me from the hospital.

(8) The difference in the feel of using neat hibiscrub over the heavily diluted form favoured by the nurses on the ward persuaded me that I should continue to use neat Hibscrub for a further 4 days at least.

REFLECTIONS AND OBSERVATIONS

(1) There did not appear to be any system in place on the ward to help visiting staff (such as physiotherapists) being updated about the infectious state of newly diagnosed patients with MRSA colonisation.

(2) Insufficient support is available at weekends to appropriately "counsel" patients who are told for the first time that they have MRSA colonisation. I am relatively well informed but could not help but think to myself does this mean I might lose my life , or a limb or is it being over cautious. I was unclear also what I could and could not do to assist in the process. I do understand that the newly printed patient information leaflets will help answer some of these questions in future.

(3) The patient information leaflet is clear and well presented. However in common with much hospital literature for patients while it is strong on WHAT to do or not do it is weak on WHY and HOW. I think there needs to be a brief explanation about the risk of recolonisation before describing how this is best achieved. I think some diagrams would be helpful in this as they would underline the need to avoid recolonisation by appropriate sequencing of actions.

(4) Having experienced what it feels like to use neat Hibiscrub compared to the massively diluted form I do think this needs to be clarified and may indicate a need for retraining of ward based staff. Although I have attended operations as an observer on occasions I have never before used neat hibiscrub. After using it in the manner suggested in the guidance the nearest I can come to describing what it is like is the application of factor 30 sun block. It is heavy and sticky. It shows up white for a while on application before being absorbed. On rinsing with a wet disposable flannel it suds up such that repeated rinsing is required to remove it before towelling dry. When used as a neat hair wash the hibiscrub thickens the hair and ideally requires a shower head to be rinsed out properly prior to drying. I noticed that as it is Hibiscrub is a 4% solution. I have not tried to work out the effective strength of the active ingredient when a capful of hibiscrub is poured into a bowl of water but it must be approaching homeopathic levels. Although I keep an open mind on homeopathy I am not a believer and would prefer not to have to rely on faith or placebo effects when it comes to the adequate control of infection.

(5) An adequate supply of cotton buds should be dispensed to patients to use with the nasal ointment OR patients provided with a bottle of hand gel to rinse the nozzle after each application. Whichever approach is adopted this should be clear from diagrams included in the patient information leaflet and in future staff training/ guidance.

(6) The need for a daily change of towel on the ward should be adhered to and not left to chance reading by individual patients.

(7) There is no doubt that in the last 4 years the culture on the wards towards control of infection has improved considerably. I was impressed by the use of plastic bags around wash bowls and of course the repeated applications of hand gel, use of aprons and disposable gloves - so well done on that score. Unfortunately for the Trust's senior management this a no-win situation because people like me are forced to question why was this not done before? In my mind - and I have shared this with David Flint (Trust Chairman), Andrew Pound (Chief Executive) and Monitor (The Foundation Trust Regulator) in the past - the reason is that local management are denied the time and space to concentrate on other than what they HAVE to do - as defined centrally by targets - and are not free to do what they SHOULD do - even if they had the inclination - i.e. to focus on what is important locally to the people they should be serving.

(8) There remains a vast gap between rhetoric and the reality when it comes to adherence to guidelines and protocols. I concluded, when with a colleague I undertook a planned but unannounced visit to test compliance with Better Standards for Better Health, that the Trust is well able to produce the paper evidence that it has policies in place for all that is required of it even when experience as patients and as Governors suggested otherwise. I believe that what I have outlined in relation to control of infection applies to a similar extent with most other aspects of the insurance policies for senior management that pass as Trust Guidelines for their staff.

(9) Unless this gap between rhetoric and reality is reduced there will remain considerable scope for complacency and inappropriate self congratulation. This worries me because MRSA and C Diff are I believe the tip of the nosocomial infection iceberg. We should be as concerned about monitoring overall levels as we are with the headline figures. l know I am preaching to the converted but do so hope that you will be able to have continued success evangelising this cause within our locals hospitals. My own post operative infection 4 years ago ( caused to my mind by wound drainage pooling on bed sheets not being attended to quickly enough while staff and visitors alike were able to come and go without any of the current precautions) will not have figured on the radar of senior management at the time. I do hope that this sort of underlying infection issue does now - although I very much doubt it. As I said I have no wish to raise my experiences as a complaint nor do I see any merit in communicating with the Trust's senior management direct - they have made it clear that they are unresponsive to any comment that might be construed as being in any way critical or embarrassing for them personally - however if you wish to draw any aspect of my experience and reflections to their attention to assist you in avoiding further complacency please feel free to quote and extract at will.

UNANSWERED QUESTIONS

I still have some unanswered questions that might well be of value addressing if only to produce clearer patient information in future.

(1) When is the best if any time to shave during the 5 day treatment course. Bearing in mind that both safety and electric razors pass very near to the nose should shaving be done before using neat hibiscrub or after?. Should the razor be disposed of or if an electric razor is used should it be cleaned with hand gel / hibiscrub after use?

(2) If swabbing is done to detect MRSA colonisation on arrival on a ward and a positive result only happens if the level is detectable , given that there is a 48 hour deley before reporting results why is a swab not taken on discharge and a patient's GP advised if the result is positive?

(3) What evidence exists for the level of dilution of hibiscrub before its use becomes symbolic rather than effective?

(4) Why are the precautions, that I saw in place once someone is diagnosed as having MRSA colonisation, not applied to all patients at all times - after all a proportion may well have high but as yet undetectable levels and this gives the appearance of a approach to the control of infection that best resembles russian roulette.


I do hope you will feel able to acknowledge receipt of this email even if you are unable to answer specific points. If you follow up on any of the reflections and observations I would be delighted. If you wish to use my personal experience as evidence to support further resources and help avoid complacency on the part of senior management you would very much have my blessing - although I acknowledge how difficult this would be for you.

I continue to wish you good luck in your efforts to coordinate the control of hospital acquired infections.

My desire is that adequte control of hospital acquired infections should in future rely on good sense rather than good fortune.

Regards

Stage 2 complete - now for the "recovery phase"

The operation was performed on Thursday morning 17th July. I was first on the list and was taken to theatre around 8:30 a.m.

I met the Anaesthetist who was reading up on my notes when we arrived on the ward the previous afternoon. He was the same guy who saw me for the first stage. We had a pleasant chat on the ward and discussed medication changes and whether I could manage without a central line being inserted if at all possible. He recognised the need to try to alter the anti hypertensive regime as little as possible as this had been a slight issue last time around and agreed that central lines were unpleasant and he would if possible manage without one.

I had the weirdest dream the night before the operation. I pictured myself on the trolley in the ante room being prepared for surgery. I could see the ceiling tiles and imagined sitting up on the edge of the trolley for the epidural to be inserted, then lying down while a canula was inserted, we discussed the best arm to use and once the canula was in place I waited for the muscle relaxant to take hold - usually I have been asked to count down from 10 and by the time I had reached 6 or 5 I would be out. So I started counting down and as I reached 5 remember thinking (or should that be dreaming?) "soon be over for me and next thing I'll know I will be waking up in POSU" - only I continued counting down to 1 and then remember thinking perhaps I should extend my right arm and wave it about a bit for the muscle relaxant to take effect. Somewhere in my subconscious I must have begun to realise that not this was not going to plan and I woke up - it was about 4:00 a.m. I did not want to go back to sleep to that dream again so I switched on the bedside reading lamp and picked up the book I was part way through. Unfortunately this was the next in the series of Stephen Booth books my wife and I have been reading( based in the Peak District) and titled "The Dead Place"!

So when I was wheeled into the ante room it was very much with a sense of deja vu! Everything went much as I had dreamed a few hours earlier. The epidural insertion stimulated 2 distinct electrical discharges down my right leg which I can't remember experiencing to that degree before - I had been warned by the anaesthetist that this might happen a second or two before hand in each case. I remember acknowledging to one of the nurses that I would be catheterised and the next thing I remember is coming to still in the ante room abut 90 minutes later still not having been into theatre.

The kindly anaesthetist mentioned he had some trouble finding a vein which would not collapse, apologised for the bruising that was already apparent but would get worse, clarified that it had after all been necessary to fix a central line in my neck ( giving direct access to the right atrium for quick effect of any substance squirted in during the operation) and in passing confirmed that I had been catheterised and had the arterial line inserted. (This would provide a dynamic monitoring of BP , O2 levels etc both in theatre and later in POSU).

I think the surgeon might have appeared about this time - no doubt wondering when he would be able to start - I noticed the time was 10:20 - so I had been in the ante room being made ready for surgery for nearly 2 hours.

As before I was aware part way through the operation of some banging sounds but this time was unaware of the feeling of synchronised movement up the table. This level of awareness happened just the once and might well have been forgotten a few days later - it was of little significance.

I did however become aware towards the end of the operation of hands pressing down and pushing forward on the skin at the top of my right leg - I think I must have been on my left side at the time. This kneeding of the skin was followed by slight pricking sensations. I guessed that I was being sewn up and that the skin needed to be smoothed forward for a better alignment of the cut edges. I was then aware of staff removing perspex panels as I looked up. I had never seen this before and realised that above my head was a squarish frame that individual perspex panels seemed to clip into. Each panel was taken away by pulling down and slightly out. I realised that the original "Charnley - Howarth" theatres introduced air flow to take potential airborn infection away from the wound and that those not directly involved in the operation had to be one side or the other of this air flow. Some would be on the dirty side only and others on the "clean" side but never should the twain meet. I had always imagined that the air flow was provided within an inflatable tent but what I saw was a semi rigid construction.

I was next aware of the registrar standing at my feet ( I'm not sure if I was still on a trolley or had been transferred back to a bed) and expressing pleasure at a good job well done with particular pleasure at achieving equality of leg lengths. I will later explain the relevance of this given the approach adopted to providing me with an almost entire metal long "bone".

I looked up at the clock in POSU once I had been wheeled into the bed bay next to the one I occupied 4 months previously when it had only been open for a few days. The clock showed just after 12:40. So I had spent nearly as long being prepared for surgery as under the knife.

On the Post Operative Surgical Unit I soon appreciated the expected absence of any pain but was nonetheless pleased that I had touch sensitivity along the skin at the from of my thigh. The swelling looked considerably less than last time around. My leg appeared to be aligned properly as I could feel the back of my knee in contact with the bed and joy of joys my right foot did not flop over to the outside. Mind you my leg had been placed in a U shaped foam trough but I was sufficiently confident of my ability to move it in a straight line when bending my knee that I felt certain the pains in my knee that I had experienced for the last 12 weeks would be behind me now.

As before I required warming up by blowing air into a plastic ducted sheet. However after about an hour I was beginning to sit up and recognise where I was. A few chats with the assigned nurse and doctor later I began to feel cold again. I was given another blast of hot air and as my blood pressure had dropped was given a couple of injections via the central line to dilate blood vessels and improve the blood pressure. To my surprise the improvement was immediate. I enquired about this and was told about the benefits of a central line into the right atrium from where any substance was pumped rapidly around the body - I had not fully appreciated this aspect of central lines before. I had received dialysis through one for 2 weeks about 4 years ago but never been conscious of the quick fix that they offered.

The respite was temporary however as a while later my Blood pressure dropped again and I again felt cold. These symptoms were suggestive of blood loss so an examination was made of the incision line and sure enough a small pool of blood had collected near to the top of the incision line ( the very area I was conscious of in theatre needing to be stretched before being sewn up).

The solution was to quickly apply a dressing on top of the initial suture dressing and then hold that in place with slabs of pressure dressings. It worked and stopped the blood loss but not before setting off an allergic reaction to the adhesive where it was in direct contact with my skin. As a result I developed some nasty blisters that still required dressing for a week after discharge.

I had last eaten about 10 p.m. the previous evening ( and then only a biscuit with a cup of ovaltine). So it was about 2:00 a.m on the Friday morning when I asked for something to eat. I was brought a ham sandwich and some hot tea.

I was the last of the patients on POSU to be transferred back to their wards and it was not until about 1:30 p.m that this was sorted out. As a result I did manage to enjoy a hospital lunch while in POSU. Before leaving POSU for the second time in 12 weeks I thought it appropriate to enquire if there was a "frequent flyer" application form that I could complete while the arterial and central lines were removed and dressed. The ward would not accept a patient with either let alone both still in place. Then it was back to the ward and the same bay from which I had left for theatre about 30 hours before.

My blood pressure was still causing concern and later that (Friday) evening the friendly anaesthetist returned and he decided to rescind an instruction to restart some of the anti hypertensive treatment. We also discussed the operation and I asked him about the mechanics behind the replacement. He drew a diagram that I shall try to describe pending a copy of the X-Ray in about 3 weeks time when I next attend Out patients.

Try to think tape worm and the coiled wire to a telephone handset to get the right image. First things first - the remnant of my own femur, still in place above the knee, was further reduced in length and now I truly believe is no more than a couple of inches. The removed bone was pulverised and used to help fix in place a new plastic cup (or artificial acetabulum). The metal rod previously inserted into the stump of femur having been removed left a hole that was exploited by a small metal spike. This spike was attached to a metal ferule about 1 1/2 inches long that both fitted on top of and enclosed the remaining stump of femur. Now we get to the interesting tape worm approach to bridging the gap inside my right thigh to the hip joint itself. Well this was achieved by slotting and or screwing additional metal sections about 1 - 2 inches long on top of each other.

I will ask the surgeon if each piece was screwed onto the previous one or if each was recessed to stack on top of each other. So this segmented building up of a metal femur continue until near the top where the femur naturally bends inwards towards the acetabulaum and counteracts this arching in with something like a flying buttress seen outside of large churches. I think this metal flying buttress became the artificial trochanter or what we all think of as out hip bone when we stand with "hands on hips". The arching of the metal substitute femur was achieved by a series of smaller sections each wider on the outside than the inside. On the xray this looked like a tightly wound coil of wire. Finally at the apex of this graceful arch was another special segment - this one fitted onto the last of the pieces that made up the arch and straightened up before giving way to a slim stem topped of with a metal ball.

All in all the one hip wonder was gradually being transformed into the tin man!

I will not describe the comings and goings on the ward other than to say that the friendly anaesthetist agreed that the epidural could be removed the next ( Saturday) morning along with the cannula through which fluids had been provided along with a couple of units of blood to help raise my Haemoglobin levels.

So as I went to sleep on Friday night I was looking forward to being unhooked ready for the visit the next morning by the physiotherapist to encourage me to stand on and walk with my new tin leg.

Before that could happen however I was given some disturbing news which is best described by reproducing an email I sent on my return home to the coordinator of infection control for the Trust describing the gap between rhetoric and reality. This then will form my next posting in a day or two. I trust you will still be interested enough to want to find out what happened next - so .......... to be continued.

... "But the bad news is ...."

In accordance with the letter (dated 2 weeks ago) confirming the operation I rang the ward to ascertain if there was a bed available. Well I tried phoning the ward. On 2 occasions the phone was not answered then it was engaged - then my wife rang and was told to call back an hour later. Then we got a call from the surgeon's waiting list co-coordinator to say the bad news was the list had been canceled as emergency demand had meant there were no beds available.

The co-coordinator could not say when the operation would be rescheduled for but assured me it was his top priority so we should hear before the end of the day or tomorrow morning.

My guess is at this stage that it will be deferred by 3 weeks. They have probably sent out invitation to come in letters to patients for the next 2 weeks so will probably bump patients who have not yet had confirmation back a week.

At some stage we will no doubt find out the real reason - although not unknown it is unusual for emergency bed crises to occur in the middle of summer. My guess is that some infection related problem in theatres or associated areas is responsible for the entire list being cancelled. In which circumstances it is better to wait for these issues to be sorted out first.

So the best laid plans need need to be rethought by my wife and I. I have however got all the hospital related toiletries etc ready and packed. These include an MP3 player, radio, plentiful supply of batteries, 2 books, a couple of Private Eyes and pyjamas, flannel and towel.

So now we .... await the call!

"House bound" reflections approaching the 2nd stage

In 48 hours time, all being well, I will be wheeled into the operating theatre after having an epidural inserted and some muscle relaxant and sleep inducing substance squirted through a cannula in my arm. I will have been asked to count down from 10 and probably have reached 6 before being unable to continue.

The next thing I should be aware of is waking up - probably in the recovery room or the new Post Operative Surgical Unit (POSU) I described in an earlier posting - after the surgery.

In between I would have been given regular whiffs of general anaesthetic to stop me from being aware of the process of:

• "unzipping" the scar from previous operations,
• "knocking out" (probably literally) the cement and metal rod that have been the nearest I could get to having a functioning right hip for the last few months before
  
• replacing it with a shiny new prosthesis that will be fixed and aligned to ensure somewhere near an optimum functioning of the knee , associate tendons and muscles that have been strained in recent months, before
  
• "zipping me up again by closing the incision needed to gain access to most of my right thigh.

Anyway I hope the operation does not hold too many surprises for the surgeons and that the anaesthetist remembers to keep checking on my level of consciousness, as well as all the other things (s)he has to attend to, as I would not want to have any awareness of the hammering that will be taking place. I was aware a couple of times during the first stage operation of metallic echoing hammering sounds while sensing that I was moving up the table. Apparently I began "flailing about" so I think I managed to find a way of communicating my slightly aroused level of awareness to all around me!

So with that approaching it is perhaps not surprising that I have been reflecting on recent experiences of being a one hip wonder and a housebound husband.

I recall, from a visit to the Viking Museum in Largs, that the derivation of the term husband was from the term "house bound". It seems the shortage of coastal farming land in Norway in particular caused the Vikings there to need to accumulate wealth by sea faring and pillaging. While the eldest sons would inherit the limited farm land the younger ones had to accumulate wealth in this way to have the dowry to get married. Once married they neither had the need or inclination to travel away from the family home so were described as being "house bound" and therefore no longer available for selection for the next away leg in the European competition they then seemed to compete in most successfully. A similar fate seems to await recently married (30+ year old) men these days. They too are no longer being available for selection - for the pub soccer team team instead of the cross channel rowing running and wrestling that seems to have been required of the Viking precursors of today's "iron man" competitors.

Unsurprisingly I have both positive and negative thoughts approaching the next stage.

As political commentators know negatives always tend to outweigh the positives - so I shall start with the 5 things I will be most glad to see the back of (assuming all turns out as expected):

"In no particular order":

1. The absence of spontaneity: Every movement, particularly if it involves carrying anything from one place to another, has to be planned in stages like a carefully managed project. In fact to follow the analogy further a successful outcome even requires mid stage reviews as well as a careful scoping of what is and is not possible.
   
   For example to wash in the morning means:
   (1) manoeuvre power chair through bathroom door ( preferably opened first!)
   (1a) Optional enabling measure - if bathroom mat is on floor carefully reach forward without tipping out of chair and place over side of bath to avoid snagging up in the rear wheels of chair
   (2) Continue straight ahead toward WC far enough to reach behind to close bathroom door behind the chair - twisting sufficiently to avoid dislocating right shoulder.
   (3) Carefully reverse into the space alongside sink - making sure sink is on the left side to avoid stretching across temporarily misaligned right leg.
   (4) Reach right to remove flannel and bath towel from heated towel rail.
   (5) Place towel folded in half across knees with open end facing away thus allowing it to be unrolled upwards to dry upper body when washed.
   (6) Half fill sink with hot water and begin washing with soapy flannel rinsing when necessary.
   (7) Use wet flannel to damp hair and then reach into cupboard above sink for brush to arrange remaining hair in an acceptable manner - i.e. away from balding front of head in a sweeping back fashion thus accentuating the few remaining dark streaks among the mostly white and few grey strands.
   (8) Replace brush and reach into cupboard for electric shaver (ignoring safety razor lather and brush that used to be the preferred method of shaving somehow inextricably associated with standing up!)
   (9) Apply pre electric shaving cream from supply at back of razor head, plunge razor into sink (its a wet electric shaver after all so why not?) and shave. On completion open razor head and clean in used water then place in razor stand in cupboard and close door.
   (10) Watch with some satisfaction as the mornings stubble arranges itself like magnetised iron filings in a pleasing pattern as the water drains away while the stubble remains on the inside of the sink.
   (11) Rinse sink with cold water , rinse out flannel and return along with bath towel to heated towel rail.
   (12) Manoeuvre chair forward sufficiently to be able to reach behind to open bathroom door.
   (13) Open bathroom door fully so as to be able to reverse out of bathroom safely.
   (14) Reverse out of bathroom taking care not to scratch door or door post on way out particularly if tempted to turn chair around while reversing - always a risky thing to do and a little like a F1 car attempting to overtake at a chicane ( I say only a little because of the relative speeds involved - OK its nothing like a F1 car overtaking but there is still the problem of losing control and driving through the obstacles instead of around them!)
   (15) Start planning the "getting dressed" project!
   
   Its even more complicated if attempting to travel somewhere as this involves transfers from chair, use of crutches, perhaps use of previously fetched mobility scooter, transfer into car and relying on someone else (usually long suffering wife) to fetch and carry bags etc or dismantle mobility scooter to fit into car boot.
   
   
2. Being a burden to others: I know this is unavoidable but that knowledge does not make it any the less difficult to bear.
   
   
3. Bio mechanical pains around the knee : The temporary realignment of my right leg means that I am unable to straighten it. From the hip the best I seem to be able to manage is about 20 degrees from straight. This means that my knee tends to be rotated to allow my lower leg to bend in toward whenever my right foot rests near to the left foot. I think this causes a different load to pass through the knee cap and tendons around the knee to what nature intended.
   
   
4. Static discharge: The rubber tyres of the power chair can generate static electricity - especially across the floor of the kitchen and utility room if I travel at any speed. I am usually unaware of this until I touch something metallic or get near to an earthed electricity switch. Then I am reminded with the shock of the discharge. What I have been surprised by is the ability to use this method to detect moisture levels in everyday things. For example the used tea bags in contact with the edge of the stainless steel sink can cause a nasty shock if I have been whizzing around making tea with trips to the fridge, kettle, sink, cupboards etc. The one consolation is that when I forget about the static build up and touch or sometime kiss my wife I can honestly say that even after nearly 35 years of marriage sparks still fly between us!
   
   
5. Limited Horizons :I have previously referred to the "expanding archipelago" of my existence but even after being able to get out and about when someone else drives my horizons have remained limited.
   
   We stretched them last week however when I attended a research panel meeting at the Royal College of Surgeons (in my capacity as 1 of 3 lay members) and stayed overnight around London first in a Travelodge and then in my son and wife's flat. This was followed by a few days in a holiday cottage in Norfolk. Although I was able to join in with these events I was well outside the comfort zone that I had established at home. These were days almost totally reliant on the use of crutches and therefore a lot of my time spent staying in chairs (as distinct from "staining chairs" - which my wife once accurately reported over the phone to my daughter, that I was managing to accomplish, to which she replied "but he's always staying in chairs"! )
   

... And now the 6 things I am most looking forward to:

1. Walking with or without the aid of a stick: My realistic goal by the end of the year is to be able to walk short distances with or without using a walking stick. I have not used muscles in my right leg for over a year and have had some of the muscle removed because of the infection. I do not expect to be running marathons but would like slowly to progress to using the static bicycle and multigym in the converted garage that also houses a half size slate snooker table that I would like to get back to using.
   
   In addition I want to be able to climb the stairs leading up to the converted loft space where the ceiling mounted projector allows me to watch sport projected onto a blank end wall of the house. The same equipment doubles up for using the nintendo wii for golf and other sport simulations which I have been unable to take advantage of for a year now, along with the wii platform bought a few months back to entertain visitors who might want to simulate skiing downhill. I can't wait to use the wii platform for fitness and Yoga exercises - my son coined the phrase "wiihab" for this, which I think we should probably patent along with a series of programs that exploit the platform's use for gentle rehabilitation. ( note to self: have a word with the community physiotherapist to see if she can advise!)
   
   
2. Getting the vote again! By this I mean by virtue of being able to do things I will no longer be totally dependent on others and will therefore be able to exercise the right to "vote with my feet" and do my own thing if I wanted.
   
   On the recent weekend break I accompanied everyone else around parts of Norfolk but tended to stay in the front car seat - it was too much of a task to continually get out and about then transfer back in when only using crutches. The mobility scooter was packed but remained in the car back at the cottage and not in the car we shared to travel around. I now know what elderly relatives must feel like on similar outings. Don't get me wrong I am grateful for being included in the plans but felt I had no right to contribute to discussions about what to do next - after all I could not do much - hence I had no vote.
   
   
3. Returning to Voluntary Work Although I continue to manage the Sheffield Talking News web site from home I have not been able to attend the regular readings and therefore stopped being involved as an occasional reader, recording technician and editor. I have also been unable to contribute to the planning of services for older people in Sheffield (POPPS) as an "expert elder" to which I was very much committed until a year ago.
   
   Although I did manage to undertake a thematic analysis for the local PCT of comments on their proposed strategy and continue to try to resurrect its Clinical Audit Patient Panel , I have not regretted being a little more distant from the frustrations of local NHS management. After all despite protestations to the contrary neither the Acute Foundation Trust (of which I was a Patient Governor) nor the PCT are truly ready to listen to and respond to local expressions of what is wanted - especially when it is at variance with national attempts to steer local decisions. ("What do you mean you don't really want choice and you just want easy access to someone providing continuity of care? You've got it wrong - choice is good for you! So we'll provide you with what you really want but don't know it yet - lots of different ways of getting semi qualified practitioners to practice on you and if you are lucky some might travel all the way from Eastern Europe for the privilege!")
   
   My continuing membership of a national panel that prioritises NHS funded pharmaceutical research is a different matter and was worth the effort of attending 2 meetings in the last 4 months. I think its because its members are sure enough of their own abilities that they do not feel threatened by the views of lay members and are therefore prepared to listen respond and on occasions even be swayed by them.
   
   So I will get back to attending the Citizenship & Involvement Group of the local Healthy Cities Partnership but probably avoid the newly established LINks body that replaces CHC and Patient Forums (until such time as the democratic deficit in local health management is addressed and corrected.)
   
   
4. Helping around the house and garden I will have no excuse and a lot of catching up to do. My wife has had to do everything while I could only watch, sometimes advise and support and occasionally help (the mobility scooter doubling up as a garden truck to fetch and carry implements, plants and weeds to and fro).
   
   During the course of the last 18 months or so we did manage to redesign the layout of an area of garden and to install a slate water feature. This required trips to organise purchase and delivery but also needed some preparatory electrical work first. I knew what I wanted to do but could not do it. So I bought the parts and found a local electrician prepared to carry out what I wanted to do. Then we needed to wait for our gardeners to find both time and men to manhandle the slate obelisk into place - it took 6 men in the end. The whole process took a lot longer than otherwise needed and I did not get to see the pleasing effect until some time after it had been completed during a brief window of mobility following a change in antibiotics but before the first stage operation.
   
   
5. Some overseas travel The seven years from the right hip being diagnosed as needing to be replaced to hopefully a successful replacement with no infection has been full of cancelled trips (to Iceland and the Arctic to see the annular Solar eclipse, to Sydney for an IT conference and visit with my son who was working there at the time, to Sienna to join some Australian friends on tour and to exchange cricket memorabilia following the successful Ashes test series the year before for example)
   
   We did manage some trips together to Germany to stay with friends and to Rhodes last year (although the infection was taking hold with a vengeance then but we did not know it) My wife managed some trips abroad to exciting places with my daughter but we feel we have not had as eventful a holiday together as we used to. We have had good times in Northumberland in recent years but always armed with a suit case full of dressings that needed to be changed daily to keep the infection under some sort of control.
   
   So with luck next year we might be able to enjoy a rail journey to Moscow via Warsaw and then a 10 day river cruise to St Petersburg before a flight back to London. I doubt I will be able to see much of the Hermitage ( but then again who does - its so huge apparently). Both the rail and boat trips will allow me to travel without having to be too energetic so if it comes off it will be a transitional type of holiday before we become a little more independent in future.
   
   
6. Woodturning hopefully moving on from one legged bowls to some more adventurous turning. I might even take up DJ's suggestion of selling some from a web site.

All being well after the operation I shall return in an even more contemplative mood and will in time add some postscripts which should fill in the "back story" of the last 7 years. I will however aim for those postings to be briefer than this one has been.

In conclusion therefore .... fingers crossed, wish me luck and .... TTFN