Monday, 23 January 2012

Go on – Knock me out!

Anaesthesia is different from sleep: pretty much instant and rather disorientating. On this occasion, at least, I rather enjoyed it, in spite of having been rather nervous beforehand, this being only my second experience of complete knockout in over 40 years. 

Crucial to making my little op a good experience was once again the standard of care given by the staff at UCH: warm, empathetic, open to questions from the patient. You will notice that I am once again referring to the hospital by its original name, University College Hospital. A taxi-driver friend put me right when I referred to it on facebook (crikey! am I connected or what?) as UCLH, which stands for “University College London Hospitals”, which is the trust that runs the hospital: what my friend referred to as a “branding cock-up” some years ago. The hospital itself—being the destination he has doubtless delivered many people to in the course of his work—remains UCH.

If you are still awake after that burst of pedantry, we will get back to the events of Friday 20 January. I slept little before rising at shortly after 5am, when I took what would be my last drink for several hours and pottered around a little too much, emptying the dishwasher and fretting slightly, so that I managed (just) to miss the fast train I had intended to catch into town. The slow train soon after that still got me to Waterloo in time to make the short connection to Warren Street and the now familiar white and green tower of the hospital that meets the gaze as soon as one emerges into daylight from the Underground.

I have reflected before and since on the journeys we make in life and their many and various purposes. Each step in the journey may be small, but by the end you are in a very different place emotionally and psychologically from where you started. To outside eyes I was any other commuter, but on this day I was once again to be a patient, making a transition from the plod of the everyday into the shallows of surgery. After presenting myself at reception on the sixth floor (“Adult Inpatients”) I sat in the waiting room for about half an hour before being called by a young doctor from the anaesthetic team. I was glad to have got this far as the only identity evidence I had on me was my appointment letter. I had been advised not to bring valuables and was only carrying cash to cover my rail fare and provide a modest surplus: no credit cards, no mobile phone, not even my door keys, since my wife would be coming to collect me when the medics had finished their work. Alongside anxiety about the forthcoming surgery wild scenes had been playing in the theatre of my mind about outlandish complications resulting in my being in the middle of London without enough cash or other means of payment (my principal credit card doubles as my Oyster card, the modern way of paying for public transport in London) and without the ability to make phone calls. While there was only ever the slightest risk that I would have to fall upon the mercy of strangers to procure the cost of a fare home or other emergency expense, I nevertheless felt a peculiar sense of nakedness being without the contemporary props of relative affluence and security that I had previously taken so for granted.

The anaesthetist looked at my throat to check that it would accommodate the tube that would help me to breathe while unconscious, asked whether I had any loose teeth that might be vulnerable to being knocked out by the passing tube (not a common occurrence), and accepted my assurance that I had no allergies to any drugs.

Back to the waiting room for another distracting read of the magazine I had brought with me. After another vague interval—I was not watching the clock but trying to go with the flow—a young surgeon called me out of the room and back to the curtained area where I had seen the anaesthetist. Here she gave me an explanation of the procedure that lay ahead to supplement that given by the consultant I had seen before Christmas and I was relieved to find out that the resulting wound was not expected to be as substantial as I had first thought. Fistulae are tricky items though and the surgeon does not know quite what procedure will be needed until the patient is out cold and can be probed to see what possibly devious route “the abnormal communication” (as the medical profession rather coyly calls it) has made through the nether regions. Those unfortunate enough to be abducted by aliens of course undergo such investigation without the benefit of anaesthetic, if their accounts are to be believed; you’d think beings savvy enough to make it all this way across the far, uncharted reaches of the cosmos would have figured out all we lesser creatures have managed to about pain management, but perhaps their persistent ignorance on the matter will have to remain one of those myriad inscrutable mysteries of the universe.

Back to the waiting room again until I was called by a nursing sister, who took me through the paperwork and wrote my name, date of birth and hospital number on plastic bands which she then fastened around each of my wrists. That done, I signed the consent form. She gave me a large plastic bag into which I would later put my clothes and shoes, but which at this point contained: hospital-issue gown and dressing gown, paper underpants, tight anti-embolism stockings and foam slippers. After this further step in the overall rite of passage I returned to the waiting room for a final period that turned out to be the longest yet, as one is not asked to change into surgical clobber until the patient ahead in the list is quite well advanced on their own path. An hour passed but then it was my time and another nurse called me from the room.

These preceding stages had all helped accommodate me to the atmosphere of surgery and I was quite calm as I changed out my everyday things and into the kit supplied. I wrestled a bit with the stockings though; the mistake was to try and follow the instructions on their cardboard packaging rather than apply common sense. Once I had got the tricky items on and looked down on my now more visually pleasing legs, I could reflect on the fact that calf-enhancing hose was common wear for men for several centuries.

"Mmmmmm, nice pins, Sir Walter!"
"Yes, stow that in your hold and sail away, Sir Francis!"

I shuffled alongside the nurse in my cheap foam slippers to the antechamber of the operating suite, where there was a nurse in theatre garb checking patients into…another waiting room. This one was very different in atmosphere to the first: it had fewer chairs and even fewer patients, just me and another man, also of course dressed ready for his own encounter with anaesthetic, knife and whatever other instruments the surgeons had in store. I made my way to a chair, joking that I needed to make sure that it was what it appeared to be as by now I was without my glasses and everything was blurred. We exchanged simple remarks but then an unbreakable silence fell between us: this was no place, radio and spacey blue light feature notwithstanding, for casual conversation. Every encounter with surgery, however minor or routine, confronts us with our mortality and everybody knows it; we may come back from that precipice on any particular occasion, but we are inevitably sobered by the experience and the thoughts it brings. The professionals, at least in this hospital and on this occasion, behaved with a priestly calm and the sensitivity to be expected of pastors, lightened by humour. In a little while I was the only patient left in the room and the attendant nurse came in and, after asking whether I would mind, retuned the radio to Magic FM from the classical station that had been the preference of the patient who had just left. I was ready for a change of soundscape as Shostakovich’s 5th Symphony, while an excellent piece, was fraying my nerves somewhat with its martial passages. An anaesthetic nurse came in and sat beside me, asked a few questions and then asked me what I did for a living; a short but lively conversation helped things feel more natural until it was at last time to go into the next room to meet the anaesthetic consultant.

Here I lay on the couch placed centrally in the room and tilted up at one end, while he introduced himself. I took the liberty of looking closely and myopically at his name badge to make sure I had heard his name correctly. We spoke about the distant country from which he had come over five decades ago. After I had pumped my fist a few times and the nurse had squeezed my arm above the elbow to raise the veins in the back of my left hand, the anaesthetist placed the needle through which the same hypnotic chemical that did for the King of Pop would soon pass into my own system. First there was a premed that made me feel slightly drunk and slurred my speech. I was given oxygen to breathe through a transparent mask and after a minute or two came the coup de grace: a large syringe of propofol that soon sent a mild ache up my arm and followed this with oblivion.

I woke up in exactly the same position and did not immediately grasp that I had been unconscious, let alone for any appreciable period of time. Minutes passed but I had no strong sense of this as I took in my surroundings again, growingly conscious of two new sensations: a raspiness at the back of my throat that testified to the passage through it of a breathing tube and a very mild discomfort at the operation site. It still took a while for me to conclude that the operation was over and that I was now in the early stages of recovery. Faces appeared at my side and voices asked me how I was feeling. I asked them how long I had been under: about 50 minutes. I felt greatly relieved and very peaceful. How much of this blissful mood was drug-induced and how much the work of my own onboard chemical factories? Each surely played a part, but knocking seductively around my mind was the thought that I wouldn’t mind more of whatever cocktail it was they had given me.

Still lying on the couch, I was wheeled to a curtained recovery area and a jug of water and a tumbler were placed on a table within reach. I was offered a hot drink and chose tea (milk, no sugar); digestive biscuits and shortbread fell from the heavens as I was encouraged to eat and drink again. I ate slowly and with relish at each mouthful, sipping the warm tea and the cool water. More tea and biscuits were offered and eagerly accepted. My clothes and shoes reappeared in their plastic bag. Time passed, I dozed some more, but by now the nurses were chivvying me along a bit. They had telephoned my wife and she was on her way; no, she was already here, waiting for me in the car at the rear entrance of the hospital just as I was putting my shoes on, having first retrieved my glasses, wrapped in a sock, from one of them. It was still all a bit trippy, a bit weird, but things were working out; the fog was clearing with gentle grace, not outstaying its welcome.

A nurse escorted me down in the lift to meet my wife and in no time at all we were home. I could sit in the car and did not have to lie down on the back seat as I had anticipated. Since then I have had only mild discomfort and have not needed the codeine and paracetamol painkillers the hospital gave me to take home. The surgeons want to see me again in eight weeks. If I have any problems my first port of call will now be the GP. I have been pottering about at home over the last few days, still sitting down carefully but feeling, sleeping and eating OK. Today I managed 26 press-ups.

Perhaps you remember the TV advertising campaign for Tango fizzy drinks that began in the 1990s, in which, typically, an unsuspecting person has a swig from a can of Tango and then looks disconcerted. The footage is then “replayed” at a speed that “reveals” that the man has been approached by a bizarre individual (in one advert, for example, dressed as Napoleon—a classic trope of lunacy) who has rushed up to him as if from nowhere and subjected him to some indignity too fast for him to take in consciously. The Napoleon figure waves a large orange rubber glove in the man’s face; on another occasion a man shouts "Oranges" into a woman's ear while she is waiting for a train. The slogan, hysterically announced at the end of the short film, is “You’ll know when you’ve been Tango’ed!”

I knew the medics had done something, but I didn’t see them do it. Anaesthesia is like sleep, but different.

Wednesday, 18 January 2012

Shifting Goal Posts

If you read the last entry you will be expecting that I will have had the operation. Sorry to disappoint, but there has been some more shuffling of dates in the last 48 hours or so, with the result that it should now be all-systems-go on Friday, 20 January. This is an improvement on the previous dates, as it happens, because my wife will not be expected at work for the four days after the op, which are when I expect to need her help the most.

I will let you know how it all goes.

In the meantime here is an image from the annals of medicine, or is it religion, or is it magic?

A skull that has received the attentions of Inca brain surgeons, or were they priests, or shamans?
A case of trepanning the light fantastic (sorry!)

Saturday, 14 January 2012

New Procedures and Old Truths

Today I went back to UCLH to meet some new people and in the process have my fitness assessed for the forthcoming operation (now due on 18 January). Specifically pre-assessment focuses on one’s ability to cope with anaesthesia, in my case 10 minutes or so of unconsciousness.

I made my way to the clinic over a bridge in the hospital atrium in whose floor were inset enlarged photographs of medical life in the early decades of the 20th century. One was of a woman closely resembling our own dear Queen standing rather stiffly beside a bed made more child-friendly by the presence of cuddly kangaroo and plush teddy bear. The little girl in the bed and the nurse standing by looked very chuffed to be in the presence of royalty and the shot leaves one in little doubt that the visit of Queen Mary would have aided the patient’s recovery no end. Surely the late Queen smiled on occasion but are there any photos showing this? Perhaps, as with our present monarch, the everyday cast of whose features tends to the solemn and inscrutable, Queen Mary’s smile was a sunny benediction.

It was all pretty quick and I was in and out of all three stages of the pre-assessment in just over an hour. Stage one was a series of questions about my medical history from a nurse, who also weighed me and measured my height, as well as giving me a couple of leaflets about the joys of anaesthetics to read on the train home plus instructions not to eat after 2am on the day of the op or drink after 5am. I find myself more apprehensive about being knocked out next week than I was the last time this happened when, aged 12, I had several teeth extracted to make room for more.

If the first stage was rather dead pan, stage two was a bit more jolly and the quickest electrocardiogram I have yet undergone. The nurse conducting the process said that this was because I was relaxed. It is reassuring to know that I am doing something right although, if this is relaxed, show me tense.

After I had taken the printout of the heart examination back to the reception clerk, it was time for the final stage of the pre-assessment: the now all too familiar blood test. Going about his work the phlebotomist sang along quietly to Adele as the sound of her latest release drifted across from the radio on the opposite side of the examination suite and we found a brief rapport in our shared appreciation of her wonderful voice. On this occasion I did not have to wait for the result of the test, trusting that it would be added to my surgical file in due course.

Free to go, I had time to spare before I was due in Richmond for lunch and so I made my way to the British Museum, but not before heeding the advice displayed here and cleaning my hands with the gel provided.

Animated virtual nurse projected within a perspex outline giving free advice by the hospital exit.
Part of a plan to have all leadership and advice dispensed in time by human simulacra.
Hmmmm, come to think of it, has anyone seen the real Andrew Lansley recently...?

I walked to the museum along streets that I have long loved, but whose rich heritage I came to value with a new intensity when I trod them with my wife and brother while undergoing chemo last summer. On the journey I noted the blue plaque commemorating the first general anaesthetic procedure carried out in England. In 1846 the house at 52 Gower Street, no longer standing, was the home of an American botanist, Francis Boott. Here, on 19 December of that year, a dentist named James Robinson removed a tooth of a Miss Lonsdale under ether anaesthesia. Two days later at University College Hospital, Robert Liston amputated the leg of a chauffeur, Frederick Churchill, while a medical student called William Squires gave an ether anaesthetic. It is comforting to know that there has been such a long history of pain management at my favourite hospital. Probably not much of a pre-assessment in those early days though, let alone soothing leaflets in plain English.

Once at the British Museum I rode the lift to the Upper Floor and ambled through rooms gleaming with priceless artefacts to the displays of European articles from the 16th century, my chosen period of study. Here I saw mazers, wooden drinking bowls for shared use that came to be replaced by individual vessels, particularly among the more affluent. Also chalices and plate, produced in greater numbers as the Protestant Reformation bedded in and the common churchgoer increasingly expected to take Holy Communion rather than that this should be the privilege of the priest alone. There were elaborately decorative gilt clothes fastenings–hooks and clasps–both on display and illustrated in small reproductions of contemporary portraits so that one could see the devices in use.

In a separate display was the Waddesdon Bequest, the gift of a Victorian member of the Rothschild family. This is a staggeringly impressive collection of craftsmanship, particularly in religious objects from mainland Europe. This little item held my gaze for many minutes. I never knew such things existed.

A rosary bead carved in boxwood in the early 1500s, Flemish work.
Such exquisitely crafted objects were produced to aid the devotions of the wealthy and the nobility and were highly prized. The bead measures no more than a couple of inches in diameter and opens up to reveal intricate scenes from Scripture in high relief.
The uppermost scene here is of the Crucifixion and in it the spears of the soldiers are as fine as hairs.
Do go and see it if you can.

On the more vernacular side I spent some time contemplating trenchers: in this case circles of wood, like large coasters, whose plain side was used for the serving of various sweetmeats at banquets and the like. Once the goodies were consumed, the trencher was turned over to reveal its painted side decorated, for example, with painted flowers, scrolls and various other curlicues framing short verses setting out various contemporary conceits. This verse sets out a bittersweet truth of human experience. Enjoy the antique spelling.

There is no sweet within our power
That is not sawled with some swore.
For so it fawles out now and then,
The worser luck the wiser men.