Necrosis (sequel to CABG)

2013 Sunday 29th Sep: Necrosis

Because my bandage was coming loose I called in at the Bitterne walk-in centre for a new dressing. The nurse said "It smells" and this alerted me to something I should have thought of much earlier.

Back in July 1999 I went on a tour of Greece in a camper van. While I was at Vassiliki, the famous wind-surfing site, I cracked my shin so badly with the mast foot that at first I thought I'd broken my leg. Instead I developed a large black bruise which gradually turned into an even larger black wound. It took a further fortnight before it turned really painful. I had stabbing pains then on my (right) shin which exactly matched the ones I was now having in my left shin.

The following day in 1999 it hurt badly enough for me to search out a Greek medical centre, which was in a village called Killini. The doctor immediately said the wound was necrotic (which obviously means the flesh has 'died'). He couldn't fix it himself but he emphasized the seriousness of the situation and so the next day I took the ferry to the island of Cephalonia, whose main town, Argostoli, has a fully-fledged hospital. For the side-splitting sum of 1000 Drachmae a doctor scraped out my wound with no more anaesthetic than a 'cooling' spray. However it all worked, I gave up my tour of Greece and made my way back to England, stopping at the occasional health centre in Greece, Italy and France. It took a long time to finally heal and I still have a visible scar. The point of this is to stress how dangerous necrosis is (it will turn into gangrene if it's not treated).

2013 Monday 30th Sep.

So with these grim thoughts in mind, and because I knew there was no chance of my getting any sleep while I still had this much pain, on Monday night I took a taxi at 1 am into Southampton A&E (for the third time). I was prepared for a long wait but after less than an hour they took me into a minor injuries unit for examination. Well aware that doctors hate their patients to tell them what's wrong I used reverse psychology and said:

"Can you assure me this is not necrosis?"

The assurance was not forth-coming although there was no confirmation either. However a little later the magic word was used and I was booked in for an overnight stay - or possibly longer. I got to bed at 5.30 am.

2013 Tuesday 1st Oct.

The following morning, Tuesday, I was seen by a familiar doctor, Syeed, Mr. Barlow's registrar. He was hugely apologetic and agreed that such infections should be avoidable, or at least handled more promptly. It's clear I was let down very badly not only by Southampton A&E by also my own GP's surgery (Woolston Lodge) where no less that four fully-qualified doctors saw my wound, plus four experienced nurses and none of them said "This looks really unhealthy." Instead they just prescribed anti-biotics or simply rebandaged it.

I was put on a intra-venous drip of Flucloxacillin four times a day, nominally at noon, 6pm, midnight, and 6am. With hindsight I believe this was a great improvement over oral anti-biotic, although 15 days after my arrival it went critical and I had 4 or 5 drips which were so painful that I declined further IVs. (see later).

At around 5 pm that afternoon I was given a 'debridement', a strange word that means they scrape away any dead or dying tissue from the wound, just as they had done in Greece. There I had my 'procedure' in public with several goulish onlookers. Here in England it probably cost the NHS a couple of thousand in strictly clinical conditions. Also they covered it with a dressing which was mainly a black sponge which is connected to a vacuum pump in an attempt to force fresh blood up to the wound and continually remove any dross.

All this (minus the vacuum) is in effect still the same as the Greek operation except that this time it was done under full anaesthetic.

I came round in the 'recovery' room, a large area packed with patients and medical staff. It was exactly 6pm when I woke and between 6 and 6.30 I jigged about in the direst agony giving continual gasps or even howls of pain. The terrifying thing about this is that no-one took any notice of me - I was just one of many marionettes sobbing their hearts out. At around 6.30 the stabbing pains at last began to subside and by 7.00 I had become a relatively sane person, and they offered me a cup of tea.

As Homer Simpson says, "This is the worst pain ever". Why, I hear you ask, along with all the other patients in that room, don't they leave you under the anaesthetic for another hour. I suppose the answer, in Roger Rabbit's words, is "Because then it wouldn't be funny". (I asked Syeed about this and he said that the pain is the anaesthetic wearing off.)

I got back to the original ward just after 8.00pm, having just missed my daughter who had reprised her earlier role of bringing in my computer, razor, phone charger, etc.

2013 Wednesday 2nd Oct.

The only redeeming feature of all this was that my steady background stabbing pains had at last subsided and I was able, after a miserable week, to sleep at night at last. I talked to Syeed again and he reiterated that I could be in hospital 'for quite a while'. Using reverse psychology again I said I had booked on a Bridge course in three weeks time. He replied that I would be unlikely to be able to go to that. So the full horror of the situation began to be revealed.

This vacuum pump is a real pain. It's quite heavy and connected to my left shin with a longish plastic tube, through which you can occasionally see the detritus being removed. Changing one's pyjamas involves disconnection and reconnection. Around two in the morning I woke up wanting a pee but completely disoriented. I couldn't recognise what room I was in and I set off for the door, before some subconscious warning kicked in and I remembered I was still connected. Still confused, instead of using one of the urine bottles, I disconnected the pump and walked out the door. Bad idea. The pump alarm went off waking everyone else in the ward.

2013 Thursday 3rd Oct.

I shared a shower with a nurse, since I needed her help with the disconnection to get me nude. Then, around eleven, a highly-qualified technician called Mark removed my dressing. What was revealed looked very clean indeed, but alarmingly deep - at least half an inch. It looked as though a lion had been gnawing my leg (see later pictures).

Mark replaced the dressing with even more care, the clever bit being that he cut a lump of thick black sponge to fit the wound and surrounded it by anchoring tape. The last stage is to put the pump 'head' back down on the outside of the sponge. When the vacuum's turned on it sucks out all the air from the sponge and all the liquid and dross THROUGH the sponge.

In general it was a bad day. It was clear that the nurses had become seriously overloaded and as a consequence every small request was responded to by "I'll do it in a minute." Half an hour later, when nothing has happened you have to ask again, and so it goes on. I needed an anti-biotic drip injection which was set up a couple of hours late and when the drip finished it was another hour and a half before they removed it and flushed it (which they are supposed to do straight away). Most annoyingly my cannula needed anchoring to my hand with a bandage (a two-minute job) which took the whole afternoon to get done.

A skin graft specialist, Mrs. Chuo, from Salisbury came in and she wanted to see the wound. I managed to persuade her to wait another day (since it had only just been rebandaged) but the other worrying thing she said was that she might prefer the wound to be open to the air instead of in a vacuum. That would put me back to where I was a week earlier. But then, she's supposed to be the expert.

Worst of all my regular blood-pressure test at around 6 pm had shot through the roof and was 200/100, insanely high for no reason. Now the hospital is full of monitors (such as personal ECGs) which trip, or more commonly become disconnected. Their failure (and incessant beeping) is often ignored for an hour or even longer. But in the case of blood pressure these tests are doggedly performed maybe 4 or 5 times a day, with the results religiously written down by hand. So when an out-of-range result appears one would imagine the nurse would report it. Not in my case. She reassured me with "I'm sure it's nothing to worry about."

2013 Friday 4th Oct.

Overnight my pressure dropped but only down to 180/95, still far too high (though this time nurse reported it to her superior).

At 10.30 they removed my dressing again and the wound looked a lot less clean than it had the previous day. The consensus between Mrs. Chuo and Syeed was that I needed another debridement (I hope recovery is less painful than last time) but I shan't get that till Monday. The sister replaced the dressing with silver gauze and a bandage. The good news was that this meant I was no longer connected to the pump - a free man again. The bad news was that it felt much like the old dressing, namely it was OK at the moment she put it on but started to hurt within 5 minutes of completion. I got her to retake my blood pressure and mercifully that was down to 150/90, still high but much, much better.

At the 6.30 check it was down to 140/88 - near enough normal, so obviously there had been nothing to worry about after all(!).

2013 Saturday 5th Oct.

During the night my blood pressure went back up again and I also began to feel very strange and sweaty. My own diagnosis (which was right) was that, despite various doses of laxatives, I had chronic constipation, probably due to the earlier anaesthetic or the pain-killer Oromorph I'd been taking. I sat on the loo from 3am to 5am with no better result than to get myself 'between the devil and the deep blue sea', i.e. part way to defecating but no further. Eventually one of the nurses gave me a suppository and an hour or so later after a struggle too obscene to describe in detail, I managed to 'free' myself. But I didn't feel I was out of the wood yet, and I awaited my next blood-pressure test with some concern.

So far I've failed to be abusive to the other patients in my ward because on the whole they've been a fairly sane lot. But the guy in the next bed, who is 85, had obviously, like me, come into hospital unprepared. When the orderly asked him 5 times whether he wanted tea or coffee it became clear he had failed to bring in his hearing aid. A little while later, when he needed to read the lunch menu he admitted he'd also left his glasses behind. When lunch finally came round he sheepishly conceded that his false teeth were at home as well. (Yes, he had a wife at home and the nurse had rung her several times, but she had declined to help.)

My constipation, and the high blood-pressure, had not yet fully resolved themselves and I was treated to another suppository plus a 'mini-enema'. The reaction was more explosive than comforting - another pair of underpants I shan't be taking home.

2013 Sunday 6th Oct.

They forgot to give me my anti-biotic drip (which I believe should have been at 2 am., having already slipped back 2 hours). Instead the nurse came rushing in at 5.10 and fastened me to the machine. When she disconnected me at 6.10 I believe she forgot to flush the cannula, though she may have done that later while I was asleep.

By 11.00 am I decided they'd forgotten my 8.00 am drip as well.

2013 Monday 7th Oct.

A truly dreadful night. I was due for my second debridement around midday so I was nil-by-mouth from midnight. In the build-up to my constipation I had (foolishly) taken three doses of Movicol and one of sodium hydroxide (all laxatives). Obviously if you do have a genuine blockage then piling on laxatives merely builds up the pressure behind it without doing anything useful. When cleared by the 'mini-enema' the log jam was now ready to break and I spent the whole night stumbling to the toilet. I even had to use the commode when I was anchored to my IV drip.

I was also in danger of getting seriously dehydrated without being allowed any drink. Around 5 in the morning I wondered whether to simply give up on the operation and to break the nil-by-mouth rule. But I soldiered on. The morning was one long wait but I did at least have a shower, although it leaked on to my bandages quite badly. I'm amazed they don't have some special waterproof devices to cover arms and legs - they have special devices for everything else.

I had a long talk with the anaesthetist. He seemed surprised that I had suffered so much pain on recovery and suggested he could 'block' the nerve to the leg instead of a general anaesthetic. However he was very concerned about the size of the wound and after I showed him the picture of it on my computer he said he would need to block two nerves, which rather put him off.

In the event, when I was in the pre-op room I learned I was to have a full anaesthetic plus a single nerve block. I suppose recovery was marginally less painful this time, relieved by two young nurses, Nicky and Charlotte, who did their best to make small talk while they fed me morphine doses. The time till my cup of tea was still an hour. I learned that they put a tube down your throat during the op and that's where I had got my bruised lip from (and why they ask questions about loose teeth). When I got back to the ward (same bed) I was diabolically tired and woosy but at least my shin was a lot more comfortable.

I broke my fast with cheese and bisuits, since I never managed to order any evening meal. Mercifullly my diarrhea had disappeared and I had not disgraced myself during the op.

2013 Tuesday 8th Oct.

I had a very good night, getting up only three times and sleeping comfortably on both sides. I suffered from stabbing pains in my chest which rather alarmed me until I found out they were the result of having four ECG press-studs still stuck to me.

The high spot of the day was watching 'The Chase' in the television lounge.

2013 Wednesday 9th Oct.

I asked Syeed whether I could go to the dentist but he was adamantly against it. I have a half-finished crown that I was due to get fixed just after my heart attack, a front tooth filling that fell out while I was in hospital, and another dodgy filling that feels as though it needs attention. But Syeed said any dental work would be an infection risk.

Here's one of the hospital procedures that goes consistently wrong. There are two levels of nurses, one qualified to handle the IV drip and one not. When my drip finishes I press my nurse-call button and invariably it's one of the junior nurses who answers it. She turns off the buzzer and says "I'll tell one of the other nurses." Then she disappears. So how long do you wait before you press the buzzer again? Has she forgotten to tell the senior nurse, or has the senior nurse forgotten that she's been told, or is she genuinely busy? The obvious solution is that the nurse shouldn't turn the buzzer off unless she can perform whatever request the patient wants. Then the system would work without everyone getting angry with everyone else.

This is how my leg looked after the debridement, horrendous but pretty clean. The faint line that goes up towards the knee is the (healed) scar from the rest of the donor wound. It goes all the way up to my groin.

Mrs. Chuo wasn't at this rebandaging. The plan remains to look at it every two days until she decides it's fit for a graft.

I was moved to a new ward. A young (in comparison with the rest of the patients) lad of 35 who had a congenital heart valve problem was told by his doctor that if he didn't have it corrected he would be dead in 5 years. He had the op but then collapsed a couple of days later with an infection. His heart stopped beating but he was revived and opened up again. So he had to do the recovery process a second time. I was appalled at such misery.

"Hell is other people." (Jean-Paul Sartre).

The wards hold 6 beds and it seems that every ward contains at least one nutter. That's an awfully high percentage. The guy next to me, whom I shall call 'R' was 87 and had had a heart valve replacement. With no provocation he started a rambling monologue of his life story which went on for literally an hour. He told us how wonderful his children were, what a beautiful house he had, that he had made two fortunes in his life and that he was only using the NHS to save 40,000 pounds. I didn't know then but he was to repeat all this incessantly to anyone who would listen. (In fact incessant repetition is a characteristic of even many non-nutters, and is a product, I think, of being cooped up in bed with nothing to do.)

I put my headphones on and listened to some music.

2013 Thursday 10th Oct.

Syeed came round and looked at the picture I had taken. The plan is for Mrs. Chuo definitely to be present on Friday.

I recognised and spoke to Dr. Martin who I'd grilled weeks earlier prior to my CABG. She said I looked fit but I said I clearly wasn't and I was still unconvinced that the bypass had been the right thing to do.

I was moved yet again (which got me away from 'R') but it turned out that 'M', the guy now opposite me was also a nutter with a verbal diarrhea problem. He had been to have a cannula fitted and when he came back he told us: "I said you're hurting me. She said, but I have to cannulate you. I said she should go back to basic training." His style of talking was that he said this three times in quick succession to every new victim he encountered. When his sixth victim, the sister, came to see him he started yet again. I completely lost my temper and shouted: "For God's sake you've told us that 20 times."

There was a shocked silence and the sister really looked taken aback. 'M' then had the grace to apologise and I felt very guilty because of all the patients he was in the worst state, hardly able to walk with rheumatoid arthritis, a bad heart problem, and lung cancer.

His wife paid him a visit at around 3pm and stayed till 7 during which time he talked at her non-stop (she hardly said a word). Then after she'd gone he rang his daughter, who was clearly neurotic, and repeated everything he'd just said over and over again. Finally he rang his wife and repeated everything yet again. In the end he had spent 18 pounds on his mobile.

2013 Friday 11th Oct.

Syeed and Mrs. Chuo looked at my wound (with Mrs. Chuo taking the bandage off). They seemed happy enough (and she took a couple of pictures for me). They are talking about doing the graft early next week, maybe even Monday. They said the op would require an epidural (spine injection which numbs the lower half of the body). This is how it looked (not a lot different from the previous picture).

Jessica, the nurse, rebandaged it very expertly but then it started to hurt worse at the shin bend. She loosened it off but it didn't help.

Bad news. There is an outbreak of Norovirus in the hospital, in our ward. I told most of my visitors not to come in (although adult visitors were still allowed).

In the evening I went to the D day-room and watched England play Monte-Negro. It was 0-0 at half-time and it occurred to me I ought to be in E4 for the drug round. Then England scored at the beginning of the second half so I hurried back. The round was in progress but not finished.

2013 Saturday 12th Oct.

My IV cannula had got painful so Ben, a Phillipino nurse, fitted a new one at 6 in the morning. (Actually my arm has swollen quite badly so I must take more notice of any pain during flushing. I believe these problems may be due to failure to flush immediately after the drip ends.)

At dawn it was raining outside but there was a wonderfully persistent rainbow. It lasted from about 7am to 8am with the rainbow foot moving off in the direction of Romsey. There was a second faint ring outside the first and it seemed to me that its colours were reversed. Also it is most strange the the grey background to the right of the bow seems far lighter than that to the left, though this must be an illusion.

The bad news was that I could hardly walk (I had used urine bottles all night to avoid getting up). The nurse gave me an Ibuprofen but it really does taste filthy. I think the pain centre is moving systematically, and it does seem to be getting progressively worse.

Yesterday evening I started to go through all the piano concertos on my computer from the top to the bottom identifying those which I consider are 'tuneful'. It's a pretty meaningless task but at least I shall have to listen to a little of each.

Around 6.30 pm there was a stunning sunset to match the morning's rainbow. It lasted for at least half an hour and the clouds were lilac against a fading blue-green sky. It made one glad to be alive.

There was a strange drama in the afternoon. To my dismay 'R', who was the guy who rambled on in a monologue for about 60 minutes when I was in the previous ward, had been moved into my new ward and he was having trouble with his bowels. He got Jessica to bring him the commode and then she left him to it (as you would). He subsequently got very upset because no-one was looking after him. I think he couldn't reach his buzzer and I don't know how long it took for someone to come. Jessica was on her break. He then moaned about his experience all afternoon, at one time apparently crying, as if it had been the end of the world. He complained formally to the sister about Jessica saying that it had been 'the worst day of his life', but I can't see that anything dreadful had happened. Needless to say Jessica was very upset.

2013 Sunday 13th Oct.

I decided to try and tot up all the drugs I've been given:

  • Ibuprofen - pain-killer (on demand)
  • Oromorph - pain-killer (on demand)
  • Paracetamol - pain-killer (on demand)
  • Bisoprolol - beta-blocker
  • Ramipril - widens arteries, ACE inhibitor
  • Stomach injection (against embolism)
  • IV of Flucloxacillin 4 times daily
  • Furosamide - diuretic
  • Atorvastatin - against cholesterol
  • Clarithromycin - anti-biotic
  • Omeprozol - stomach protector
  • Amlodopine - to reduce blood pressure

    Far too many.

    2013 Monday 14th Oct.

    A microbiologist doctor came round and said he favoured keeping me on IV until Thursday's op (and maybe longer). This was despite my discomfort and protests. I didn't have any knowledge of IV drips but here is a quote from Wikipedia on 'extravasation' that I looked up when I got home:

    "Extravasation is the accidental administration of intravenously (IV) infused medications into the extravascular space/tissue around infusion sites, either by leakage (e.g., because of brittle veins in very elderly patients), previous venipuncture (such as from blood drawn for laboratory tests prior to therapy), or direct leakage from mispositioned venous access devices. Extravasation of medication during intravenous therapy is an adverse event related to therapy that, depending on the medication, amount of exposure, and location, can potentially cause serious injury and permanent harm, such as tissue necrosis. Milder consequences of extravasation include irritation, characterized by symptoms of pain and inflammation, with the clinical signs of warmth, erythema, or tenderness."

    The article further recommends:

    "The IV infusion should be freely flowing. The arm with the infusion should not begin to swell (oedema), get red (erythema), get hot (local temperature increase), and the patient should not notice any irritation or pain on the arm. If this occurs, extravasation management should be initiated."

    "After the IV infusion has finished, flush the cannula with the appropriate fluid."

    I certainly had one bad swelling that lasted about a week. I blame the nurses for not flushing promptly enough. In all I had about 60 separate IV drips, and of course this makes everyone "casual" about the risks.

    One particular case sticks in my memory. An Italian male nurse called Ayo set me up on the drip at around midday and then said: "I'm off on my break. When it finishes, get someone to call me." When the drip completed I rang my buzzer and got a nurse called Fran, whom I asked to get Ayo. "He's on his break," she said. "I know," I replied, "he asked to be called." "He's on a 10-hour shift," she snarled, "I'm not interrupting his break." And with that she stormed off.

    Now it's reasonable for nurses occasionally to lose their tempers with awkward patients, and even to shout at them. But her behaviour was medically quite unacceptable. However angry she was she did not have the right to prejudice my treatment.

    2013 Tuesday 15th Oct.

    My daughter had bought me a 'limbo-bag', which is a plastic bag to cover the leg, with a neoprene seal. I had an early all-over shower using it. It was marvellous. This is exactly the sort of aid I would expect the hospital to supply. Unfortunately for me it was to be rendered useless as soon as I had the skin graft because the donor site (which also has to be kept dry) was on the other leg.

    A French doctor called Simon came to redress my wound around 2pm. He took the old dressing off with the help of some aquasel and then began to pick at the dross with a pair of tweezers and a very sharp knife. There's no doubt that he was very dextrous. It hurt occasionally but not so badly as the recovery hour after Syeed's debridings. Trouble was an hour or so later I was afflicted by exactly the same 'fidgeting' as I had suffered on the previous two occasions. Jessica said this was exactly how nerve-ends felt.

    The pain has persisted, on and off, right up to 9.30pm and may continue into the night.

    Louise came to replace my cannula and put the new one on my right wrist. Before she left I complained that it didn't feel right - it stabbed me if I bent my wrist backwards any distance. She said she would come back and fix it after she finished all her blood tests but she didn't.

    Around 5.30 it was clear she had forgotten and a nurse called Wendy had a go at putting a new one on the back of my left hand. However it was far too painful before she'd even got it inserted. A more senior nurse came by at about 7 (just before the England/Poland match was due to start) and she had 3 more unsuccessful tries before giving up. So I missed my 6pm drip and am now waiting for a doctor to ring back, able to do the job.

    'R' looked awful in the morning, slumped in his seat. I seriously thought he might have a death wish. He had a visitation from a group of doctors and they were arguing as to whether he needed anti-depressants. Jessica told him this and it seemed to animate him. He found someone to tell his life story to and then three or four more victims and seemed to perk up. He said he was going to discharge himself from hospital today and got a nurse to find his bag and clothes. His son came came in around 7pm and he obviously discouraged him from precipitous action. I can't see that he's fit enough to go home. Southampton have agreed to transfer him to Bournemouth but there is no bed free, and it looks doubtful that they could do the transfer while we are still on a Norovirus embargo.

    Gerry, a male nurse, came about 10.15 (after I'd fallen asleep) and did the cannula, but made heavy weather of it - he got blood (mine) all over the pillow and the floor. He eventually put it on the back of my right hand but it still hurts.

    2013 Wednesday 16th Oct.

    Our ward is still 'closed'. No new admissions, so the number of patients is gradually dwindling as people get discharged and one of the rooms is actually empty.

    My 6am drip failed, i.e. it was so painful flushing the cannula that we gave up. Subsequently Louise came round again and fitted one on my left forearm. I said it felt OK but 5 minutes after the start of the drip it began to sting quite badly and continued for the whole hour. I made up my mind that I wasn't going to accept any more drips. It's not that the pain is intolerable (or anything like as bad as my shin at its worse) but pain is nature's way of telling us there's something wrong and I really feel I must have developed some reaction against Flucloxacillin.

    Around 4pm a surgeon from the graft team came round with a consent form for me to sign. Among the risks was 'amputation' and I told him I wasn't willing to accept that. Instead they have to let me die. I also told him of my decision on the drip. He repeated that IV would be safer from the reinfection viewpoint but I insisted that instead he prescribe some oral alternative.

    An hour later the anaesthetist came round. I asked her why she was proposing a full anaesthetic whereas Mrs. Chuo had suggested an epidural. She said the decision was hers and she favoured full. I asked for what reason and she said she would not know in advance how I would be positioned and where the donor skin would come from. I asked her why she didn't find out from Mrs. Chuo in advance but she had clearly never spoken to her because she called her 'Mr. Chuo'.

    I seem to be getting into confrontational situations.

    'R' did a walk along the corridor this morning but only after a ridiculous amount of goading from Heather, the physiotherapist. This afternoon a senior doctor came in to talk to him and used a very sound argument. "We've done our bit replacing your heart valve, now it's up to you to make it worth-while by making the effort to exercise."

    I have the impression that 'R' has been here well over a week (I first saw him a week ago).

    2013 Thursday 17th Oct.

    Time for my skin graft.

    I was in the shower by 7am and around 8.15 they wheeled me to the theatre. I saw Mrs.Chuo and handed her a note I'd written saying I wanted to able to sleep on my left side after the op (because my right shoulder is painful to lie on). The donor graft is on my right thigh on the front, which is OK.

    The recovery was grim but not as bad as the previous two ops. I'm tied to the Vac machine, which is bad news, but even worse is that I'm on two days 'bed-rest' which means I'm not allowed to get out of bed - it's bottles and bed-pans. The reason is I'm not supposed to pull the edges of he graft,

    They moved room 26 (including me) to room 27 lock, stock and barrel. Then they deep-cleaned 26 and made it part of the 'open' hospital (whereas we're still in the 'closed' part). There's been another case of vomitting and diarrhea so we don't get open till Sunday.

    I slept all afternoon. Mercifully my shin doesn't hurt.

    2013 Friday 18th Oct.

    The ward is down to 3 now, as 'M' was moved to be nearer the nurse station. We were all awake between 3am and 5am. 'R' went off on to one of his rants to the nurse, complaining that he'd been taken to the toilet by another nurse and then left there. What does he expect?

    I noticed a blotch of blood on my sheet and rang for the nurse. She changed the sheet but did not check where it was coming from, which was what I really wanted to know.

    I woke at 6am and realised there was more blood. I asked the nurse to check my urine bottles for blood but she said they were OK. Then she spotted that my orange hospital pyjamas had blood on them near the new donor graft. We looked underneath and there was quite a lot of blood.

    A doctor came round at 8am , looked at the blood, but said it was 'dry' now.

    Simon came by around 9am and said that such bleeding was not unusual. He wasn't going to change the dressing but someone would, later in the day. I mentioned that I was on 'bed-rest' and he seemed surprised. He said I should be walking and in any case it was OK to sit in the chair (deep joy).

    I moved into the chair and revealed a large stain on the underneath sheet. The donor graft was still seeping.

    'R' complained that I was getting a lot of attention. I refrained from commenting that copious bleeding was a tad more serious than being left on the commode.

    I asked the ward sister if I could go to the toilet and washroom and she said yes. My real hope was to use the toilet and avoid a bed-pan but unfortunately I wasn't able to go.

    Around 1.45 the senior nurse came by to check on my graft and said they would cover it up with another dressing but not remove the old one. She studied my loose-leaf book but could not find anything helpful. Then she saw a pile of papers on the side cupboard. They were Mrs. Chuo's write-up and must have been left there since yesterday when they brought me back. They said quite emphatically that I should be on bed-rest and I could only move to the chair on Sunday. So that put me back in bed. The nurse said "Wait there, I'll get the dressings," and disappeared, leaving me on the bed with my trousers round my knees and my privates on show.

    I stayed like that for five minutes but then dressed myself. After 45 minutes the Portuguese nurse Beth appeared, said she wanted to look at the graft to see how big a bandage was needed, and she too disappeared. Once again I got dressed. She returned after ten minutes and put several sticky bandages over my single leaky one.

    'R' was moved to a single bed room for 'special observation'. That left only two of us in my ward.

    2013 Saturday 19th Oct.

    It seemed very hot during the night and around 11pm I could not get to sleep. Tossing and turning I 'wrenched' my shin, which I'm sure must have disturbed the graft. Then I got to sleep pretty well and was woken at 6.45am.

    I thought I wanted to go to the toilet and I got them to wheel me and my vacuum pump to the loo. But then I couldn't go. I absolutely do not want more laxatives. I'm using the chair though I'm not sure I'm allowed to.

    I talked to Trudy, the head nurse, and she persuaded me to take one dose of Lactulose before giving up and using a suppository. It should kick in sometime this afternoon.

    Dinner came and went. I asked if I could have one more try at 'natural child-birth' before using a suppository and lo and behold, it worked. Not the full ration, I'm sure, but a good start.

    2013 Sunday 20th Oct.

    Not too bad a night, though I was awake from 2.15 to 4.15. My blood pressure is down - which I attribute to the Amlodopine they've given me. My weight's down to 96.0Kg. I was 110Kg before my CABG. Where's it all go to?

    2013 Monday 21st Oct.

    A very strange night. Because of the Norovirus threat the patients in my area have not been replaced when they leave. This has left me sharing a 6-bed ward with only one other patient, who I shall name 'B'. 'B' is 80 and perfectly lucid, though he did complain of seeing 'squirrels' earlier in the week. The doctor told him that he had a very low sodium level in his blood and this was apt to cause hallucinations, such as seeing parts of a picture 'move'. He instructed 'B' to lower his fluid intake down to 1500mls a day, and to take salt on his meals.

    Last night I got to sleep shortly after 10.00 and slept OK for a few hours, though I was conscious of 'B' talking to the nurses, instructing them "This bit goes here. That has to go through there." It didn't make any sense and I was initially annoyed that he was speaking so loudly. The nurses said "Get some rest," to which he replied 'I don't need any rest." At about 4am I became aware that he was 'fidgeting' almost continuously, knocking things and moving his bedclothes. The wards were very quiet and this has the effect of making even minor sounds irritating, though I would easily be able to nap during the day with far more background noise.

    Around 5.15am I gave up and decided that since I couldn't sleep I might as well sit in my chair. From there I was able to observe 'B' and I must say I've never seen anybody behave like that before. Basically he just kept repeating the same actions over and over again. He was wearing slippers (in bed) and they would come off. He then attempted to put one back on, failed, so sat up and put them both on normally. When lying down he kept fiddling with the sheet, trying to get it into some 'position' that would satisfy him. Or he would roll it down from the top.

    As far as I could tell this activity had literally been going on all night (in the morning he said he hadn't slept at all). But he didn't seem to be aware of his repetitive behaviour. When one of the nurses came in he would instruct her to get his legs and the bedclothes into some state she could not understand. I assume this is all a result of some hallucinations, though I have no evidence of that.

    From being initially annoyed I became rather sorry for him. Here was a lucid person who was being afflicted by some derangement. With my earlier experience of demented patients in the hospital I tended to see them as they currently are - demented and irritating. I'm sure my children remember my mother as a dotty old lady (she suffered from Alzheimers) whereas of course I remember her as she used to be before, but afflicted by an incomprehensible illness.

    They moved us into the next ward, deep-cleaned our ward, and then moved us back again. This is the official end of the Norovirus restrictions, so that's very good news. 11th Oct was when it started so it's been 10 days. I have the impression that only 3 or 4 people have been affected.

    I've noticed that, apart from newspapers, no one here except me reads anything. Of course they don't listen to music or type a diary, either. It's an appalling waste of spare time.

    2013 Tuesday 22nd Oct.

    The doctor came round and said my blood results are very good, i.e. a low white corpuscle count, which means no infection.

    2013 Wednesday 23rd Oct.

    Strange happenings in the night. This illustrates how helpful and accommodating the NHS can be. Vijay, an Indian patient who had had a heart attack while on holiday was brought into the bed opposite mine at about 7pm. He spoke only Tamil. With him were his daughter who spoke good English and his wife. After a good deal of coming and going they installed themselves in the 'room' made by his bed screen curtains. So we all went to sleep with two females in a male ward. At 11.30 a young man arrived, his son, to replace the two women. He must have spent the rest of the night sleeping in the chair.

    My comments about no-one doing anything while in here weren't quite accurate. I've seen one man doing a crossword with his wife, and another younger man who had a computer and earphones. However it has dawned on me that 'B' does absolutely nothing at all - no reading, no music, no TV. He just stares. He went into his repetitive routine again last night, but then mercifully fell asleep.

    2013 Thursday 24th Oct.

    A doctor came by around 9am and said they wanted to take off my VAC bandage today but weren't sure whether Southampton was to do it or whether Odstock (i.e. Mrs. Chuo) would want to. He would phone them and find out. The day went by and 6pm arrived without any action and I had given up hope. Then Mrs. Chuo appeared by herself. She had been in surgery earlier. She very carefully removed the plastic holding the sponge in place and then lifted the sponge out. Deep joy! The graft looked perfect.

    The pink skin is mine (from my right thigh) and the faint mottling is due to the gauze that had been covering it. She used tweezers to remove remaining bits of gauze and then rebandaged it with a lot of loose dressings covered with an extensive wrapped bandage. Deeper joy! She said I could go home tomorrow, but that I must come back into the plastic surgery department of the hospital next Wednesday for the bandage to be removed for the last time. The graft source should remain undisturbed for another two weeks.

    Even deeper joy! After a continuous nine and a half weeks of being marinaded in anti-biotics, they have finally been stopped. (Over the last few days I've been taking 20 tablets a day because they had no large ones.)

    2013 Friday 25th Oct.

    Dreadful night. My leg started to stab around 8pm and continued through till 4am in the morning. I would lie down for ten minutes until the pain got too bad and then I had to sit up until it subsided. This despite two doses of paracetamol and an oromorph, which seemed to have no effect. Then at 4 am it seemed to subside and I slept till 6.30am and then a little bit from 7 to 8.

    During my stay I had been doggedly refusing to take the Furosamide (diuretic) tablets they gave me. A new patient was given a dose the previous evening and he lost a staggering 6Kgs in weight overnight (all fluid). The staff were all extremely concerned but he said he felt fine. He won't enjoy taking the Potassium tablets later (see my notes on urine in my previous blog).

    I noticed that 'R' was still in his one-man ward, sitting in the dark. I believe he's been in hospital well over two weeks and looks as though he may never leave.

    They wanted my bed urgently so after I'd had a wash and changed into proper trousers they banished me to the discharge lounge. But I didn't get away till 1.00 pm.

    Home at last! My house felt cold and damp, though the weather is really quite warm.

    Conclusions

    Most people who spend time in an NHS hospital have nothing but high praise for the staff. I think the dominant factor in this is the treatment of lavatorial problems. I had my own toilet disaster which the nurses dealt with promptly and without complaint. Along with most of the public this amazes me. How a young nurse can bear to mop up after an old man, and even give suppositories or whatever without revulsion is beyond my comprehension. We also have an enormous debt of gratitude to the large number of foreign staff without whom the NHS would collapse.

    However, not everything runs smoothly and this is a list of situations where I believe the NHS failed me, sometimes quite badly:

  • Allow choice, especially for older patients. Old people do not want to have major operations and are less able to recover from them. In my case I believe I could have got by with some sort of drug regime and avoided a bypass. I believe the NHS feels legally obliged to propose the 'correct' treatment required for a full cure and they railroad patients into taking this. It might well require some sort of government legislation to do what I want - an unbiassed consultation followed by the ability for the patient to sign an indemnity - but we cannot go on as we are, frittering millions of pounds on costly procedures for old people.

  • Too many drugs. The doctors prescribe new drugs which the nurses then administer without necessarily any consultation with the patient. They have got themselves into a mode where they seem quite happy to prescribe drug B to counteract the effects of yesterday's drug A. The human body is an adaptive system and does not react predictably like a machine to these onslaughts.

  • A&E admission. This was a turning point in my treatment. An A&E receptionist should, at the very least, be able to make a shrewd assessment of how ill a patient looks. I was very ill and too weak to fight when I made my fruitless visit to A&E on the 8th September. Had I been correctly handled it could have avoided my subsequent deterioration into necrosis, and could have saved the NHS two debridement operations, a skin graft, and 3 weeks of in-patient costs (let alone hours of pain for me). More generally, post-operative infection is obviously an inevitable risk. The hospital appeared to make no provision for monitoring this. Was it my fault for turning up unannounced at A&E? I didn't know where else to go.

  • Woolston Lodge Surgery. My own GP was in effect in charge of my post-operative progress and I was let down very badly. I was seen by four doctors in all, Dr. Adey, Dr. Regan, Dr. Casey and a tall blonde female doctor whose name I don't know. There were four nurses Zoe, Lisette, Debbie, and Shiela involved in the bandaging. The doctors never did anything other than prescribe anti-biotics, pain-killers and redressing. If things had continued without my taking things into my own hands would my leg have become gangrenous and would I have lost it? That seems unbelievable.

  • Pain-killers. I said at the beginning of my first blog that pain is nature's gift. I still believe that even though in the meantime I have myself consumed a small mountain of pain-killers. In particular in the spell where my leg was deteriorating, if pain-killers had not existed would my discomfort have been so much greater that my GP would have been forced to take positive action? ECGs are commonplace nowadays. Is there no way an ECG could make an accurate measurement of pain to alert the doctor, just as blood-pressure readings alert him to heart problems? Asking patients to rate their pain on a scale of 1 to 10 is clearly highly subjective and quite unsatisfactory.

  • Constipation. In the regular nurse rounds of 'Obs' (observations) each patient is asked "Have you opened your bowels today?" If the answer remains "no" for too long then laxatives are prescribed (and represcribed). This is a dangerous philosophy because if it fails it exacerbates the problem and eventually the patient gets thrown from constipation to violent diarrhea.

  • IV drip. It was a flagrant failure of nursing care that I was so often left with an IV drip unflushed. There are two obvious solutions. Firstly the nurse call buzzer should not be habitually reset by the junior nurse but only reset by the nurse who can handle the call. (This would avoid a source of much aggravation between nurses and patients, not just in the case of the IV drip). Secondly, why on earth aren't junior nurses taught and empowered to do the flush? It involves only an unplugging operation, and the plugging in and application of the flush. These are all no-brainers.

    I hope there are no further sequels to be written.