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.

On The Post Operative Surgical Unit

The operation for the filleting of my right thigh ( to remove infected bone and soft tissue along with the metal implants that had contributed to the 4 years of post operative sepsis) took a little longer than planned.

I was given an epidural ( for the second time in my patient experience) for which I was glad. Because of the past history of Crohn's disease my previous experience of General Anaesthetic followed by days of lying flat in bed has been that I would be sick for many days and then bloated.

I now know that these conditions contribute to pseudo obstruction of the bowel - for me at least. The treatment for this has in the past involved the insertion of a tube into my stomach through my nose with a small bag attached to collect stomach secretions until the pseudo obstruction resolves itself. The devise is called a nasal gastric tube. Not only is this process painful but to my mind moves me significantly, toward the alien end of the human/alien life form axis!

The other contraption that has a similar effect is the insertion of a "central line" into the side of my neck. This contraption consists of a plastic tube from which a number of other plastic tubes split off to be connected to monitoring devises and/or therapeutic equipment like kidney dialysis machines. I have had a central line inserted three times ( in fact during each of the last 3 operations) fortunately all done while under the influence of an anaesthetic.

I have never had to endure both nasal gastric tube AND a central line at the same time and think If I did I might never re-emerge as human but would remain completely alien - in my mind at least!

Because of my history of renal impairment I was due to be nursed after recovery on a recently opened Post Operative Surgical Unit. This is less invasive then intensive care and is separate from an associated High Dependency Unit. Its purpose is to provide a facility to enable constant observation, monitoring and specialised treatment after an operation.

I went down to theatre around 1:00 p.m and recall 3 occasions when the general anaesthetic must have worn off sufficiently for me to hear the sound of hammering ( to remove the old implanted hip joint) and feel the effect of the hammering moving me up ( or down) the table. I mentioned this afterwards to the Senior Registrar who commented that yes I had tried to "assist at times". I asked if this meant was I talking and giving advise? To which he replied "no you just decided to flail about a bit!"

Around 8:00 p.m I regained consciousness. I noticed my wife was sitting at the end of the bed. I think I acknowledged her but was unable to converse much at the time. I gathered however from the discussion she was having with the young doctor attending to me that the operation had not gone altogether as smoothly as planned and that I was in a state of shock. All I can remember is that Martha - the nurse assigned to me - was asking questions and I that I felt very cold.

I could see that to my left was a computer screen split into about 8 displays of what I assumed were traces of heart rhythm, blood pressure, respiration among others.

I was aware that in response to saying that I felt cold Martha reached behind my head to the right and I felt warmer. I noticed that in place of a sheet and blanket I was under a series of plastic / paper tubes about 3 inches across. There must have been sealed double layer around each tube and it was into this space that warm air was circulating to warm me up.

I next looked under this arrangement and saw my right leg, which I could not feel. The word "akimbo" came to mind as did the image of Meryl Streep in "Death Becomes Her" after tumbling down stone stairs shortly after becoming to all intents and purposes immortal. It was not a pretty site. My right foot was turned completely out. The outside of my right knee ( slightly bent) was lying flat against the bed. I also noticed how swollen my right thigh was. I am used to the swelling involved in normal hip replacement but this seemed more excessive than normal. All in all I had no feeling of my right leg belonging to me and what sensation I did have was analysed by my brain as a lumpy mattress on the right side of the bed!

I was vaguely aware of saying goodbye to my wife as she left. Richard the young doctor returned from time to time - on one occasion he had to re site an arterial cannula. This, along with the central line inserted in my neck allowed very accurate monitoring of various vital signs. I could see the small contact that was reattached after the cannula was successfully inserted and remember thinking about "nano technology"

At this time I therefor had a venous cannula through which I was receiving fluids, an arterial cannula for monitoring purposes, a catheter, an epidural line into my back, a central line on the right side of my neck. In time each would be removed as I would revert to being increasingly human again. Fortunately there was no nasal gastric tube to achieve a full house!

Around 2:00 a.m. I think I had recovered sufficiently to be conscious and to my surprise was asked by Martha if I wanted anything to drink. I assumed this would mean, as I had experienced before with a very dry mouth, sucking on a sponge lollipop followed by sips of water at 15 minute intervals. To my surprise Martha was offering to bring me a beaker of coffee complete with spout to aid drinking. What is more I was even brought some toast and marmalade!

About 6:00 a.m I became aware of staff coming and going and handing over. Richard introduced me to Amy who would be taking over from him and would ensure I was fit to return to the ward later that morning.

A few hours later Amy returned and ensured I had some more food - in this case some vegetable soup which as she said would do me "more good than all these fluids and drugs were putting inside you."

I was shown a red silky half sheet that was in fact a roll of smooth cloth. Amy said that this should accompany me to the ward and be used to assist in moving me around the bed when required. It was never used for this purpose and was in fact discarded. I did however make sure it was taken home with me ( it was labelled "for single patient use only" so I assumed it was disposable) as I thought it would help me get into and out of bed with my swollen unco-operative right leg.

I will reflect on the potential benefit of this patient handling "device" in later postings as I recount my experience of differences among the ward nursing staff in their understanding of the importance of patient handling techniques generally but particularly for those with no hip joint.