J: “I recommend you stay awake throughout this operation.”

Those were the disconcerting word spoken to me by Dr. Handel, my anaesthetist, when we had the pre-op discussion about the process of replacing my hip joint. Yikes!

There is not much news in this post. People have expressed curiosity about staying awake during a major op like this. So if that interests you read on. If it’s not to your taste (there is also quite a lot about pain post-op), then just skip this post and there will be news updates along soon (all good).

It is standard practice for the anaesthetist to see you on the day of your op. Their job is to keep you alive on the table and if they do not think you are fit to go, nothing happens. They have all your pre-op data but need a proper talk to understand your general health and get an idea of your fitness etc.

Dr. Handel knew I’d been seen by a colleague a few days before so wanted mostly to discuss the anaesthetising options.  For this op these come down to general anaesthetic, epidural and spinal block.

General anaesthetics are avoided if possible as they are higher risk and basically the more you are knocked out the slower it takes to come round and you can feel sicker post op. So though the idea of being totally out of it during a big operation is appealing you can see the downside.

I did not like the idea of an epidural since I had such a bad time with this during my nephrectomy. It was explained to me that for this op the insertion needle would be between different vertebrae where there is more room, so it is generally easier.

However Dr. Handel wanted to use a spinal block in combination with a sedative. Again this goes into the back with a needle, and it numbs an area from your hips down. Because it does not go up to your lungs your breathing is normal, so does not need to be managed, and of course you stay awake. They stick in a catheter once you have the block (as of course you lose control of all those muscles since they are in the zap zone).

“I have done thousands of hip operations like this” said Dr. Handel “and in the last 15 years the spinal block is preferred for ones like yours. People don’t like the idea of it at first, but it is very very rare for there to be any kind of a problem”

Dr. Handel explained that I would have a sedative and actually it was the same (or similar) to that used for a general anaesthetic. He would be able to dial/down up the amount of sedative I needed/wanted as required and I could talk to him all the time. I decided to go for this on the basis that if I could not talk to him I’d be out of it anyway and, more pertinent,  he has rather more experience of hip ops than I do.

He also said I could take my own music with me. I have my phone loaded with music, and earphones, so the idea of being able to do that and dial up the volume if I wanted was pretty good.

I had previously discussed with Mr. Bishay. the surgeon, that I would be second on the list but earlier he’d said that the Admin team had put me down for the pm, but they could reshuffle the list. Dr. Handel confirmed that but said Mr. Bishay had requested an intensive care bed (as I was deemed high risk) but none was available. He was inclined to go ahead anyway as sometimes patients need intensive care unexpectedly and they would sort it one way or another.

However the morning went and nothing happened. Having been waiting for this op for months and then having the big discussion about staying awake during it the long wait was quite stressful as you may imagine. In the end I was operated on last (about 3:30pm) and due to poor comms problems no one had mentioned that someone had insisted I not be operated on until an intensive care bed was available.

I ended up being a bit weepy with anxiety going down to the theatre after all this wait, and with all the discussions we’d had in recent weeks about infection risks, this being my third attempt etc.

The anaesthetic team, led by Dr. Handel, were great and soon put me at my ease. I’d found the team in May (for my nephrectomy) a bit laddish, but these guys were generally more gentle and empathic.

The spinal block went in much the same way as the epidural – sit on the side of the bed and bend over to open up the vertebrae. A quick local and the needle goes in. Right first time, all totally painless. At some point they stuck a catheter in but I had no idea.

I was then wheeled into theatre and slid across to the table, clutching my phone and earphones. Usual arrangement with lots of big lights in the middle. The whole thing was surrounded by a kind of box of shutters attached to the ceiling which could be pulled down. This is so that positive air is pumped into the top (filtered) and anyone coming in and out of the door won’t bring unfiltered air with them as they are entering a higher pressure environment. The shutters can be raised or lowered according to where the guys are working.

Yes, I say guys, as this was an all male environment save for one junior nurse who appeared briefly to ask if she could help. I commented on this and they agreed it was pretty much the case, especially among bone surgeons where the job is more physical, as you will learn.

I lay with the shutter area roughly above my chest and a big blue paper/cloth screen was put up to separate me from the surgeons. My chest was then covered with a papery blanket I was told would inflate with warm air to keep me warm during the op.

The surgeons then tested my body to see if I was reacting to whatever it was they were doing. I didn’t so the spinal was obviously working.

The anaesthetist was somewhere near my head and I could talk to him as I wanted. Having had a good hour’s chat that morning meant we both understood each other and helped put me at my ease. He and his assistant helped me arrange my phone and music and get me in the position I wanted. Mr. Bishay had said he would book the theatre for 2.5hrs but in reality it was expected the op would last an hour less than that. Nevertheless I’d built a playlist for that full time. I decided to start with some soothing Thomas Tallis then move onto Mahler’s uplifting Das Knaben Wunderhorn and from there to Toumani Diabate playing the Kora, an African instrument I love, then finally good old Dylan. I had no real idea whether this would be sequenced right, but we got the music going and off we went.

The best analogy I can think of – which is not great – is that it’s like being numbed at the dentist. You know they are whacking at your teeth but you can’t feel anything. Actually it’s better since you can’t see the action and it is not going on in your head but another part of the body. You can’t hear the knife cutting of course, but you can when they get out the drills and saws.

I had the volume up enough on the phone so I could not hear them talk, but low enough so I could talk to the anaesthetist. What surprised me most was the amount of hammer whacking that went on at times. I thought they might have to chisel out the socket for the hip but this was real whacking like when you cut bricks with a bolster and shook my whole body. It was not at all uncomfortable or painful, just strange. I thought there must have been a good 100 whacks over a few sessions though maybe I imagined it.

I’ve had some trouble setting up music on my phone sometimes and my playlist didn’t work but I talked to the anaesthetist about it and he just took the phone and played me whatever albums I wanted. I dialled up the volume when I felt I wanted to lose myself in it then down again for quieter times.  I also found that I got quite hot and kept asking them to cool down the heating blanket until eventually it was turned it off.

The op must have taken at least an hour – maybe 90 minutes. I forgot to ask, but the time went quickly enough and the anaesthetist said he’d given me the minimal sedative dose which he was very pleased with. That’s good as it meant I was perfectly perky and happy afterwards with none of the post-op grogginess and nausea which came after my general anaesthetic in May – and none of the vomiting you sometimes see people doing in recovery wards.

The biggest delay was now with my mattress of all things! Hospitals are big on air mattresses these days which massage you to prevent sores from lack of movement – a constant problem post operatively especially with older people. I’d had one in May which I didn’t like but had been on another for the last 10 days which worked fine. Anyway the bed they brought in had a mattress which was taking ages to inflate. The orderly insisted it was fine and after half an hour I was slid across to it. It didn’t seem right to me though as we were to confirm.

Post Operative
I was taken from theatre to a recovery ward as the intensive care bed was not available and waited there an hour or two with lots of attention from a nurse – and our son came to see me as well which was lovely. Then I was taken down to intensive care.

I’d been in intensive care in May and found it a rather strange place more like a shed than a ward. It’s  huge room perhaps 30m long with some beds at one end and some the other. All are well spaced and at the end of each bed is a dedicated desk. The width of the ward is at least double normal so a patient opposite you is nearly 10m away.

My nurse was running about 4 beds that night and I could see she was not entirely happy about the workload. My wife was also in the ward at the other end which was good to know as we were more able to get reports on each other’s progress.

I made several comments about my mattress and was told it was working. Eventually I got hold of the senior guy, Jose, who I recognised from May and he agreed it was faulty and they found me another bed and mattress and switched me across. A rather painful experience while it lasted but worth it as I have found that the massaging of the mattress does a lot to relieve pain as well as helping prevent sores.

As you may imagine it is a busy ward and there were quite a number of big interventions in the night as very sick people came in needing lots of attention. But I rested pretty well. At 6am a junior doctor came round and discussed things and I spoke of how well I was feeling etc.

By 6:10 I started getting some pain in my leg and asked another nurse to get mine to come over – she’d been on the other side of the ward for hours. I then escalated that as she did’t show up and the pain in my upper leg started getting quite severe. I knew I’d been prescribed oxycodone as a ‘breakthrough’ so asked for that. A ‘breakthrough’ is a drug you take on top of your ‘normal’ ones to deal with peak pain. I could take oxycodone every 2 hours i.e. as much as 12 doses a day.

The trouble with this system is that the nurse has to get a signoff, so even once I’d got a nurse to pay attention (my pain was visible to all passers by at this point as I was in tears and rocking myself for comfort) it took her ten minutes to do the admin and get the drug – and then of course if takes about 20 minutes to kick in.

My nurse then eventually came over and suggested my leg was also not in the best position and changed my bed angle etc which helped. I had said that the night before and been told it was fine…

The drugs quietened me down for a couple of hours but then the pain came back quickly  and my new day nurse, Michelle, who was really excellent, got my dose increased and this lasted until about noon. She then asked me if I needed more and I said no, since though I still had pain in my upper leg it was more like bruise pain, not like being stabbed and the knife wiggled about. Mistake, since she then had to go off and spend some time with another patient and within minutes the old very sharp pain came flooding back.

I got another dose for that but the pain would not go. A consultant apologised for not having got on top of it sooner. During the afternoon they kept increasing the doses and trying additional drugs but with little effect. Come 6pm an anaesthetist came and offered me a kind of spinal block into the groin which he said would numb me from hip to knee for about 24 hours. I went for that immediately. It involved putting two big syringes of fluid in through a large needle but was remarkably painless. He used ultrasound to find the right spot. He said it would take about 20 minutes to work. It didn’t. Another anaesthetist explained that if it was not working after an hour then it wasn’t going to. Apparently the way the nerves and veins work is a bit complicated and though they had gone for the ‘right’ vein it obviously wasn’t the right one for my hip and pain locality.

So I had to put up with the pain which was not making me cry any more but just incessant – about level 6-7 out of 10. I was particularly concerned that I was by this time due to move out of intensive care to an ordinary ward – that had been agreed at 6am. Michelle had been on my case all the day and I was not going to find the same level of support in an ordinary ward.

I was also having additional pain from the leg pumps they put on me. These are like splints and pump your lower legs to simulate walking – and thus reduce the risk of clots and thrombosis. Trouble was every time the right leg was pumped it moved my whole leg and twisted it slightly, guaranteeing an extra shot of pain every minute. I asked if they could be removed and was told no but eventually a kinder doctor said they could be swapped for and I now have foot pumps instead which are almost as effective and without the pain.

At least I was going to an orthopaedic ward – Forrester. There had been talk of moving me back to William Budd (oncology) but I knew there was only one physio at Budd and he was run off his feet. Forrester is geared up to rehab for hip replacements and since the next step is to get me out of here on two legs I wanted to maximise my chances of decent help to do that by going to a fracture ward.

I was quite worried about the transfer as the intensive care beds are special to that ward – the others all swap about. Every time I got moved I got more pain. In the end it was OK as they put two beds in tandem – the new one without a mattress -cranked mine up and just slid me and the mattress along to the new bed.

Michelle came up with me to the new ward to brief my night nurse. I got her to explain that although my oxycodone was ‘on demand’ I didn’t want to have to ask for it and wanted it every 2 hours automatically.

Things got off to a poor start when my 8pm drugs and oxy were not given until 9pm and I was very concerned about how I would spend the night having been in constant pain for over 12 hours. Fortunately once things got going the night nurse settled in well and woke me to give me the drugs, rather than waiting for me to wake in pain and ask for them.

By morning I was feeling pain free and was told I had not been given any breakthrough oxycodone at 4am (I still have a slow release background dose). That was good news as it meant I was now OK without it.

I think it is unusual for someone to have as much pain as this post operatively with a hip replacement and I certainly know other people who have not had anything like this kind of trouble. It is thought that it is all the other cancer stuff I have got going on that makes it worse.

Physio delay
During the night the orthopaedic registrar had expressed some irritation that I’d not had an X ray. I’d been told they would X ray the hip on the way to the ward to make sure the new joint was all correctly located etc. but as we ended up going so late (8pm) they skipped it. I was taken down instead about 9am and annoyingly being slid onto a hard bed for that from the mattress brought the pain back so I was in tears for a bit again, but luckily the moment I was back on the mattress it eased. In a way that was a ‘good learn’ as previously new pain would take forever to go, whereas this meant that if I did have temporary pain it would recover more quickly.

About 11am a junior doctor came and said she had reviewed the X ray and the joint was all correctly fitted and had not moved. However there was not quite as much cement in part of the joint as might perhaps be considered OK to proceed with physio. I asked what this meant, rather alarmed, and she assured me that it did not mean a possible trip back to theatre. She needed a senior consultant to review the X ray and it would either mean he would deem it OK or they would have to take my rehab more slowly (meaning presumably a longer stay).  
I saw the doctor again in the evening and asked about progress on the review. She said the consultants had all been tied up with a difficult operation and had not been able to look at the X ray yet which would now be in the morning. That is frustrating as I know the physios work weekends in this ward so I feel I have lost a day. Also there could be exercises I can do in bed to help get things going but I don’t know what they are. I hope we can get this sorted tomorrow – but then it’s a Sunday, so fingers crossed there will be the right people about.