First off, aorta explain that the above pun doesn’t really work when the blood vessel that is the subject of these articles is an artery and not a vein but try as I will, I cannot come up with an artery-based song title.
Anyway, to briefly recap, in Part One I outlined how a hospital referral to investigate a urinary tract infection led to the chance discovery of a large abdominal aortic aneurysm (AAA) and how side effects of the cystoscopy led to my emergency admission to hospital with sepsis. My original motivation for writing was to encourage all male readers of 65 and over to take advantage of the free screening available to them on the NHS as AAAs, which are largely symptom free, are usually, like mine, discovered during investigations for other, non-related conditions or, tragically, post-mortem.
As it currently seems to be fashionable to criticise the NHS on the grounds of inefficiency and waste, I thought it might be interesting to consider my personal experiences of the service I receive between my discharge from hospital following treatment for sepsis and my subsequent re-admission for arterial surgery.
One of my greatest fears while being treated for sepsis was that I would be in no fit state to drive my grandson to York as promised for his interview and tour of the University’s Electronic Engineering Department. In the circumstances, it was probably a daft thing to do, but two days after being discharged, I did the 600 mile round trip to York but accompanied, at her insistence, by Mrs P. who wanted to be there ‘to keep an eye on me, just in case’ and I was very glad that she did. The trip went well; our grandson loved York, the university campus, the department and its academic staff and, as an added bonus, we drove over to our home town in the evening for a pub dinner with my brother and his family. All in all, the trip was a great success and I’m so glad that I took the risk.
The Cardio-Pulmonary Exercise Test
Over the Christmas-New Year period, the television adverts that caused me the greatest annoyance (apart from the statistically improbable mixed-race family ones) were ones for that sodding, over-priced, internet-linked exercise bike. Little did I know that I’d shortly be doing my own version of ‘Peloton’ only with far more serious implications.
When we got home from the York trip, I found a letter from the hospital summoning me to a one-hour pre-admission cardio-pulmonary exercise testing session with a consultant anaesthetist. How things have changed! Eighteen years ago, prior to my heart bypass operation, I attended Southampton General a few days prior to admission for what now seems like a cursory physical examination involving bloods and an ECG. This time at Bournemouth, the process would involve a variety of tests including a 15 minute stress test on an exercise bike during which I would be ‘taken to the limits of my endurance’. Gulp! This, for some reason, got me worried and I was consequently quite nervous when, accompanied by my wife, I duly presented myself at the hospital two weeks later.
The first part of the session was performed by a nurse. The usual height, weight and blood pressure tests were carried out and then I was connected to an ECG machine after which different adhesive contacts for the exercise bike were stuck onto my chest and I was given a special exercise top to wear. The anaesthetist asked a lot of questions regarding my medical history and then did a series of lung capacity tests that involved my taking deep breaths and then exhaling for an unfeasibly long period through a special mouthpiece while wearing a nose clip. The data obtained from this allowed the computer to calculate my predicted performance on the exercise bike and then programmed it to test me against these criteria.
As I’ve been regularly attending the hospital Heart Club gym on a weekly basis for the past 18 years, I’m quite used to riding an exercise bike which I usually crank up sufficient to provide quite stiff resistance but only for short periods. This test was different in that after a face mask had been fitted that would allow the computer to measure both my oxygen intake and CO2 output, I was asked to start cycling until I reached a comfortable speed which I would then be required to maintain as best I could throughout the test. I soon settled down to what I understand cyclists refer to as a ‘cadence’ of 73 rpm and the test began. So, there I was spinning the pedals easily for what seemed like ages while the anaesthetist watched the screen, making occasional encouraging comments like, ‘You’re doing really well,’ and, ‘That’s great, keep it up. It will start to get harder soon and I want you to keep on until you absolutely can’t do any more.’
For the first 12 minutes or so it was all pretty relaxed and easy and I was soon miles away as I imagined myself cycling along a beautiful French river. I could do this for hours.
Although I was expecting to hear the bike click or shift gear at some stage, the change in effort required was completely imperceptible. Mrs P. told me later that the only difference she was aware of was to my breathing as it became progressively more laboured. Finally, when I felt like I was approaching the summit of Mont Ventoux and could only manage 58 rpm, the test ended and I was left gasping for breath, sweating profusely and with my pulse hammering away like the clappers. Clearly, the anaesthetist hadn’t been too worried about my aneurysm going ‘pop’ during heavy exercise and this I found strangely reassuring.
After he’d entered the important data into a PC program that calculated my personal risk factors, the anaesthetist told me that as I’d achieved 98% of my predicted score, he was more than happy to refer me to the vascular surgeon as ‘a good risk’. We then talked briefly about the surgical options which are: a) do nothing; b) repair with stents and c) repair via open surgery, together with their advantages and disadvantages. It was sobering to be told of the statistics involved in open surgery to repair the aorta, my preferred option, as apparently there is a 1 in 50 chance of dying during the operation and a 1 in 100 chance of not surviving for a year following surgery. Obviously, the fitter the patient, the better the chances of survival and full recovery.
I left the hospital feeling relieved at having done so well in the stress test but in view of the statistics, in a decidedly contemplative frame of mind. It was only later that I metaphorically kicked myself for not having taken a camera to the hospital so Mrs P. could get some shots of me on the bike and that is why, in a clumsy effort to lighten the tone of this article, I’ve gratuitously added some of my cycling-related holiday snaps.
The very next day, to my great surprise, there was a message on our answerphone from the consultant vascular surgeon who had spoken to me at length during my hospital stay, asking me to contact her on her mobile so we could ‘get things moving.’ We had a brief chat while she was driving between hospitals during which I confirmed my tentative preference for open surgery. We provisionally agreed that 14 January 2020 would be convenient for the operation as it would give me another four weeks to regain my health fully following the sepsis and also to get Christmas and New Year out of the way.
Then, the following Saturday evening (it’s always at the bloody weekend) my piss turned dark brown again. This time though I wasn’t worried as I reckoned this was good news as the other kidney stone must now have broken up and been flushed out as grit by the large quantities of water that I’m now in the habit of drinking. By Monday morning all was back to normal and there has since been no recurrence.
Then something worrying happened. Two days after the stress test, I received a call from the hospital cardiology department asking me to attend that afternoon for an echocardiogram. No explanation as to why I was being called in was offered and this got me thinking in my typically pessimistic way that a cardiologist must have found something not quite right in the cardiopulmonary exercise test recently carried out. This did not bode well.
So once again I presented myself at the hospital, anxious as hell about the examination which was to be carried out by a young trainee. This examination is very similar to an ultrasound and is carried out with the patient lying on his or her back and then side while a scanning device is pressed firmly onto the skin of the chest and back and, once correctly positioned, angled rather than moved to obtain the required data. A scan is also made of the neck to check blood flow to and from the brain and I could hear the squishing sounds of my heart valves operating and blood flowing through my arteries. This was very strange and reminiscent of a foetal heart monitor.
‘Is everything OK?’ I asked anxiously when the test which took about 20 minutes was finished.
‘I’m sorry but I’m not allowed to say anything as I’m only a trainee,’ the young woman explained, ‘but I now have to get my supervisor to come and check that I’ve done everything right and have got all the necessary information, so perhaps you could ask her?’
When the senior staff member arrived there was much technical chatter between the two of them so again I sought reassurance that all was well.
‘Well, so far as I’m concerned,’ she said, ‘I can find nothing at all to worry about and that’s what I’ll be saying in my report to the consultant who requested the scan.’ Fair enough.
‘So why was I brought in at such short notice then?’ I asked.
‘Oh, there’s nothing sinister about that, it’s just that we had a cancellation for this morning so we thought we might as well get you done before the Christmas break.’
So, with a deep (but as it turned out, premature) sigh of relief that all the tests were now over, we went home only to find yet another bloody letter from the hospital awaiting our return, this time asking me to attend less than a week later for another bloody CT scan, this time of my heart.
Then, to my surprise, on the following Saturday afternoon prior to the scheduled CT scan, the consultant vascular surgeon rang me on my mobile to let me know that at their recent case conference, the consultant cardiologist had thought that in view of my having had a bypass so long ago, it would be a good idea to do some in-depth heart scans ‘just to be on the safe side.’ When I told her that I’d already had the echocardiogram and was booked in to have the CT scan two days later, she was genuinely surprised at how efficiently the system was working and was most apologetic that she had not rung me earlier to let me know that the heart examinations were being scheduled purely as a precaution, given my history of coronary artery disease.
Yet another CT scan
Having had an abdominal CT scan only three weeks previously, I was not unduly worried about it, only about what they might find. This time I had to put on a hospital gown that opened at the front so they could attach contacts to my chest before having a cannula inserted in my arm for them to inject the contrast dye through mid-scan. Immediately prior to the scan I was also given a couple of sub-lingual nitroglycerin tablets to open up my arteries. Anyone who has had occasion to use a nitro-lingual spray to control angina pectoris will be familiar with the bitter taste and sudden, sharp headache that this drug can cause.
This time the scanner was smaller in diameter with a semi-transparent red plastic section immediately above my head through which, when the procedure began, I could see a rotor whizzing round inside at a rate of knots before the bed moved me into position for the X-ray images to be taken. It was all very Star Trek but sadly without the presence of Dr McCoy and his Tricorder. Probably due to the effects of the nitroglycerin, the contrast dye was much more noticeable this time and I felt decidedly flushed as the liquid travelled up my neck, into my face and then down my body where it caused the weird sensation that I was emptying my bladder. All this is normal.
And that was it; wait ten minutes before the cannula is removed and then get dressed and go home.
D-Day is announced
Then, on the Saturday after Christmas, the fateful letter arrived informing me that my surgery had had to be re-scheduled for 28 January and that I was therefore required to attend a meeting with the surgeon who will be performing my operation on 08 January followed a week later by yet another pre-admission screening.
Meeting with the consultant vascular surgeon
My experience to date of evisceration has thankfully been restricted to that of food animals in abattoirs but as pigs and humans are internally very similar, I have a very good idea of what my innards will look like and consequently can imagine them spilling out at the first stroke of the scalpel. Fortunately, instead of hanging me up by the heels and letting gravity do the job, the various internal bits and pieces will simply be moved to one side to provide access for what essentially is plumbing work to be carried out.
Maybe I asked too many technical questions and received too many detailed, no-holds-barred and often grisly responses but when I started to feel a bit woozy, I decided it was time to shut up.
This meeting was very useful as I now understand exactly what is going to be done to me, how long it will take and what I can expect to find in the way of bodily attachments when I wake up later that day in the Intensive Care Unit. It was interesting to learn that there is also another small aneurysm in one of my iliac arteries that the surgeon will deal with at the same time and also that my sense of taste may, and nobody knows why, be temporarily affected by the procedure.
I came away from this meeting feeling much better informed but somewhat subdued as the realisation of what faces me hit home together with its inevitability and imminence.
The final pre-admission assessment
I found this meeting with a vascular practice nurse extremely helpful as it answered all my practical questions about the admission procedure, which of my current medication to stop taking and when. The nurse went through an incredibly detailed medical history form with me followed by a thorough physical examination focused on my respiration, heart and circulation. Before we left I was given a booklet about admission to the hospital on the day of the operation together with detailed information about the operation which I am currently trying to pluck up courage to open.
To date, I cannot fault the NHS and the treatment that I have received. Every one of the dozens of staff that I have so far met from administrators, cleaners, porters, technicians and nurses through to consultant anaesthetists, urologists and vascular surgeons have treated me with courtesy, respect and understanding. My main problem has been coping with the waiting. No matter how much I try, I can’t get it out of my mind that the clock is ticking down to my appointment with the surgeon in little more than a week and the strain is beginning to get to me. Oh, and last night I steeled myself to look at the aneurysm information leaflet and frankly, I wish I hadn’t.
To put it simply, I’m scared.
© text & images Tom Pudding 2020
The Goodnight Vienna Audio file