Today, we’ll learn about an Abdominal Aortic Aneurism (AAA), a potential for error that could lead to erectile dysfunction or premature death, good friends, the scalpel skills of an amazing woman and my wonderful family.
I’m guessing the word “erectile” got your attention so here is the tale.
Seven years ago this week I went for a routine scan of an Abdominal Aortic Aneurism often affectionately referred to as a triple “A”. I’d been looking after it for about twenty years and knew that it had been getting larger but only because the scans had shown it so, there is no pain or discomfort and that’s the danger. If you are reading this and you’re called for a scan, please don’t ignore it. It largely affects men and you’re likely to receive a letter when you’re over sixty – to repeat, don’t ignore it. The process is entirely painless and if you do have one and it gets treated you’re going to get a few more years of life – now that’s got to be a good return!
I walk a lot with friends and prior to being mended I had modified my lifestyle and told them what the problem was so that they understood when impromptu stops were necessary to allow heart rate and blood pressure to return to more acceptable levels especially on the moors and hills of my beloved Yorkshire. My friends even ensured that the walks were moderated to allow me to take part and for this level of care together with the affection and support I received after the operation I will be forever grateful.
So I turn up at James Cook University Hospital with my wonderful sister Mary who’s come along just in case I need a lift home. It’s her birthday today so the plan is to go for a meal at lunchtime to celebrate. It has never been necessary to action any other plan as there are no drugs to take for the procedure so there’s no need for lifts home etc. In fact, all that has been necessary in the past is a new entry in my diary for the next scan at a time the specialist nurse feels appropriate.
Discovering Some Issues
I present myself at the unit for this routine procedure, it’s now occurring every six months as the aneurysm has been getting bigger but just at the rate of a millimetre per year. The specialist nurse greets me like a long lost friend as she’s been looking after me for a number of years and always refers to me by my first name. The sonar specialist is a male this time and he prepares the area of the abdomen around the belly button with some jelly that has the combined effect of creating a better contact with the skin and lubricates the area for comfort. He’s been busy for a couple of minutes when he exerts a little more pressure and I flinch, it’s not much but the specialist nurse, who’s been watching every move like a hawk, sees it and steps in; “Did that hurt?”.
“Just a bit uncomfortable”, I reply.
“Have you got your measurements?”, she’s directing the question at the sonar specialist.
“Yes, I’m just going to do the double-check”, he says.
“Skip that, I’ll have a quick word with Monica, she’s just along the corridor”, she’s speaking to both of us but addresses me as Mr. Layfield which makes me think there is an issue and she exits the door. A few moments later Miss Hansrani, the vascular surgeon enters the room and introduces herself.
Miss Hansrani – Vascular Surgeon
It’s not an overstatement to say that this lady, her team and the NHS are responsible for my continued ability to do the walks that I do and enjoy the life that I lead. Without them all I would be dead.
So I’m Admitted to the Ward
After a reassuringly thorough examination which includes some quite firm pushes just below my belly button and watching my face. After several minutes she tells me that I need to be admitted to the ward. I think it’s for further investigation and have a vision of going home to get a few things to present myself next week after the bank holiday; however, she has other thoughts and tells me that she’ll walk with me to the ward and book me in herself.
I’m a little anxious now and tell Mary that I’m being admitted and would she mind driving the car back home. She agrees that she could but has no intention of leaving me until she knows the complete story.
A couple of hours later and the complete story is that the aneurysm has grown to over twice the size that a normal aortic artery would be and the fact that it is creating some discomfort is not a good sign.
The surgeon has been looking at my notes and tells me that my level of fitness and age would suggest a complete open repair rather than stenting and she would leave me with a leaflet which turns out to be a six-page fully comprehensive document that explains the full procedure. She also tells me that if I’m willing to go ahead she’ll move her elective list and operate first thing in the morning.
At this point, I’m getting the gravity of the situation and as she makes her way to the door I tell her that she may need to know that I’m taking a medication that thins the blood called Clopidogrel. She turns on her heel looking a little worried, then, after a pause, tells me she’ll discuss it with the anaesthetist and other colleagues.
A short time later she returns and informs me that the drug will be suspended for the foreseeable future and the operation would be postponed for a week so that what was already in my body would be replaced with fresh unaffected blood cells. I ask to go home and get another negative response.
By now my family have been informed and appropriate hospital clothing is being sourced. By evening time visitors are arriving including my daughter who brings assorted clothing appropriate to my new residence in the ward. Both of my daughters and my sister are the runners, all I have to do is get better and they contributed to that in an unquantifiable way. Emma has become the local support worker, Vicky the long-distance support worker and Mary makes herself available for literally anything; I’m truly grateful and love them all.
I’m in the ward nearest the nurses’ station because of the risk of rupture of the aneurysm and a cannula has been inserted in my left arm. I’ve already had one in my right arm and it has been uncomfortable so they replace it – with a bigger one – in the other arm to be able to fill my body rapidly with fluids should the aneurysm burst.
A Drug Addict Tries Our Patience
The first night has been ‘interesting’ as a drug addict is resident in the adjacent bed and has been shouting and screaming for several hours. He’s feigning acute pain and demanding morphine for his supposedly poorly leg. He’s been given several shots but wants more. The junior doctor is not in a position to give him anymore as he’s at his prescribed limit and the addict has been shouting at full volume for over two hours and the other patients in the ward are desperate for sleep. I’m glad the operation has been postponed from today as I’m exhausted from the combined effect of being kept awake by this local character and the residue of the sleeping pill that had been prescribed to help me sleep through the din.
The ward staff have been wonderfully professional. The nurses and health care staff have spent many hours trying to placate and calm him by gentle persuasion and by firm management and then by distraction. They have no space to move the addict and to my shame, I’d just be happy if he was moved into the car park and abandoned. I’ll regret having these thoughts when I’m a little stronger and less sleep deprived but my attitude right now is – “give the bastard the drugs and if he dies, he dies”.
This close up shows the tricky procedure. The alternative is to have stents inserted that reinforce the artery but that technique is generally used on older or less fit patients. I’m so glad I’m a walker and grateful to my walking friends for the encouragement.
A Little Light Reading
Today, I’m moved to a ward a little further away but still close to the nurses’ station and given a six-page document about the operation and what will happen with a promise that the vascular team will be along to answer questions. It’s very comprehensive with diagrams and risk factors and some detail of the recovery process.
I read through it a couple of times and write questions in the margin ready for the specialist.
The ward staff are wonderful. There’s a cheery cleaner who needs to move the beds to deliver a thorough and efficient service. Then there’s a lady with a trolley full of coffee, tea and biscuits equally cheerful and both with an astonishing ability to remember names. The health care assistants are hands-on and do all the regular stuff that I thought nurses do; however, the highly skilled graduate staff nurses and sisters now seem to be more administrative and spend most of their time pouring over paperwork and a computer at the station, there seems to be an abundance of paperwork.
There are six beds in the side-ward and four men occupy them. I have made friends with all of them over a couple of hours and when not discussing our various ailments I’ve managed to absorb the details of the explanatory document and have a few questions for the surgeon.
Late in the afternoon, the surgical team have started their rounds and there’s a bit of a buzz on the ward. I notice this change of atmosphere over the week. Each time a consultant arrives on the ward there’s a change. It’s not better or worse, it’s just different. The consultant will question each of his or her patients and then conduct some hands-on examination whilst asking questions and explaining procedures to the surgical or medical apprentices all eager to learn and delighted if they’re asked to step forward to palpate or inspect something in more detail. As the consultant leaves each patient one or more of the junior doctors are left with questions to clarify or get extra detail and instruction are left regarding today’s care.
Mortality Statistics v Risk to an Erection
In this little ward the four men are lying about on their beds in various states of relaxation. One is lying across his bed reading a book, another is sitting upright with a magazine slightly tilted towards the window to gain the extra light, the third is dozing between consciousness and sleep breathing slowly and I’m sitting on the side of the bed with the explanatory document and list of questions.
In to the ward come the vascular team and after a cursory chat to one of the men who will be leaving today, they move on to me.
“Have you had a read through the document?”, she asks with a smile. As a female surgeon, she’s not unique but there’s certainly not as many as there are men and it’s great to know that there’s been an increase in the number of ladies in this honourable profession.
“Yes”, says I and add, “I’ve a few questions”
She seems to be delighted that I’ve made the effort and it becomes obvious that some folks just don’t want this level of detail and prefer them to just get on with the operation. I just like to know.
“This question’s almost trivial…”, I say, “…how big will the incision be?”, I quickly follow this up with the assertion that it really doesn’t matter, I’m just interested but the reply surprises me.
“I’ll cut from here”, she puts a finger on my tummy four or five inches to the left of my belly button, “and take it to here”, she traces an imaginary line across my tummy just above my belly button to about four or five inches the other side. I’d expected a vertical cut, like a zip, from below my belly button to…well, I really didn’t know where.
“Oh!”, I exclaimed, “…that way”. There’s an upward inflexion in my voice turning it into a question.
“Yes, I need to move stuff and I require plenty of room”, she explains, “Have you an issue with a big scar?”
“No”, was my emphatic response, “I’m happier with a scar than the alternative”
By now I’m in full flow and one of the junior doctors asks if I would like a bit more privacy. My response is negative, there’s nothing that I’m embarrassed about and the other three are half asleep or reading, not that it matters anyway so I plough on.
“According to the document, the chance of me dying is 5 to 7 per cent, what’s the percentage at JC?”
She’s really on the ball here and reassures me that the mortality rate is an average that has to be published, she’s not prone to losing patients but she HAS to warn me of other complications before consent forms are signed. She adds that if the aneurysm bursts then I will die and even in the hospital with all the expertise and equipment the likelihood of my death rises to over 80% so, she pauses and rubs gently on my arm and says firmly but reassuringly, “…it really does need to be dealt with, even if we use stents”.
So more questions are asked about infection rates, loss of lower limb mobility, kidney issues and general supplementary questions. The other three patients are showing no interest.
“Right!” I say, “Could I move you to this page”, I’m pointing at a paragraph, “What’s this about erectile problems associated with cutting a nerve?”
“Ah”, she replies and I get the impression that not many ask about this, she continues, “The nerve that triggers an erection in men runs along the side of the aorta and if I happen to cut that then you won’t be able to have an erection”
“Hmmm, that’s how I read it”, as I say these words I scan the room. The other three are not on their beds and as I look around I find them sitting on the adjacent bed, bolt upright, legs swinging like three wise monkeys listening intently to the conversation.
“Err, would you like a little more privacy?”, it’s the junior doctor again.
I’m smiling, greatly amused at the change of interest of my fellow inmates, “No”, I say, “I’m happy for us all to understand”
I turn back to Miss Hansrani, “I’d really rather you didn’t cut that nerve then”, I’m trying to make a joke but then feel a bit embarrassed, not at the subject matter, bodies and their functional parts have never been an embarrassment, it is due to the naivety of the question. Of course, she wouldn’t do it deliberately but the operation is tricky so I need to be aware.
“I’m very careful”, she asserts and holds my hand to make the point. “Any other questions?”
“No, not just now”, I reply, “but I’m sure I’ll think of more”
“I’m here every day”, she says and makes her way out of the ward. Just as she reaches the door I deliver the Columbo question, “Err, just one more thing. It’s regarding the mortality rate. If seven in a hundred don’t come back, how many of these ops have you already done, you’re not at 92 are you?”
I’m rewarded with a twinkle-eyed smile…
I scan the other beds and see my fellow inmates are now back in their respective positions reading, dozing and relaxing. Sex talk over, they’d lost interest. I’m amused that they’re not interested in mortality rates but rivetingly interested in the ability to have an erection.
I’m smiling to myself now as I toy with the permutations. Worst scenario, I could be dead but stiff or alive but floppy. Rigour Mortis might be good for the erection but not so good for my social life whereas being floppy is what things are like most of the time and I’m getting on a bit and the odds are good that she’ll manage to cut around the nerve and not through it.
My options are quite simple. I could have a stent with all the backup and annual return for scans to ensure it’s where it was put. I could have the open operation with some dramatic consequences if things don’t go to plan but the odds are good, or I could refuse all and let it take its course and be dead in a period of time yet to be determined…
…It looks like open surgery is good.
The risk of it bursting combined with the necessity to rid my body of the Clopidogrel means I’m confined to the hospital for a week before the operation and whilst it’s tedious I understand the reasons. There are plenty of friends coming to see me and provided I don’t leave the hospital grounds I’m even allowed to walk outside (having reported my intentions to the nurses at the station) and on one of the wonderfully sunny days that’s exactly what I do and you can see the write up from the link at the end of this missive.
So, tomorrow is the day and the week has shot by without incident. Patients have come and gone from the ward but there are three with whom I’ve become quite friendly.
On the morning I’m surprisingly not anxious and my three friends wish me well. A porter arrives and puts me on a bed, another surprise, I thought I’d go down in a wheelchair. It’s not far and I’m transported to a kind of waiting area then into pre-op where the anaesthetist greets me with a big smile and lots of assurance. He’s got an apprentice today and I’m asked if I’d mind if she does the insertion of the needle into my spine.
“Please go ahead”, I say. I’ve spent nearly all my working life in and around education and I’m fully behind anything that will help educate or train. She struggles a bit and the consultant tells her he’ll go for a little walk and the moment he’s out of the room in it goes and lots of plasters are added to hold it in its place. The consultant returns with a smile, it’s clearly a technique he’s used before to take the pressure off the trainee and it works.
He tells me that when I wake up I’ll be in the Intensive Care Unit and there’ll be lots of tubes in my mouth and fastened to cannula(s) in my arms, I’ll also have a catheter. He adds that on the first night, pain relief will be the responsibility of the team but beyond that there’ll be a button to press that will deliver predefined amounts of pain relief; however, this will also be controlled by time to avoid an overdose.
All of the above had already been described in detail so there are no surprises and it’s good to be fully informed.
I’m talking quietly to the anaesthetist – then I’m not! Miss Hansrani and the team do their stuff…things don’t go quite according to plan as she finds a little more disease than she expected and she has to cut two ‘collars’ from the latex and stitch them onto the two ends of the aorta to strengthen it then she stitches the seven inches of new tube on to the collars, it is; however, very clean with no coagulated blood that can be a feature of aneurysms probably because of the clopidogrel. As it’s not as straightforward as expected the team are on their feet for nearly 8 hours.
Intensive Care and Recovery
The recovery nurse is speaking gently to me and stroking my arm, “You’re done now George, all went well”, she’s smiling and talking again, “All done, it went well”. She probably repeated this many times but I only registered it once and I think I smiled as I nodded acknowledgement. Speaking is not an option as there is something in my mouth and down my throat. When this was explained to me, I did think all of this would be uncomfortable and would make me want to gag but it’s fine.
Not a Good Patient
I want to be a perfect patient but it isn’t the case. During the long first night, I become aware of someone who is coughing continuously. One of the last things that the surgeon had said was that I had to avoid chest infections, in fact I’d been told to avoid any infection at all and the proximity of the poor soul who sounds like they’re in the last throes of death is giving me huge concern. I drift in and out of sleep but mostly out.
At some point there is a flurry of activity and as my eyes focus there is a sea of concerned faces, apparently, my heart stopped beating and triggered various alarms. I don’t remember the actual event presumably because I was technically dead or, at least, not in possession of a beating heart. When I look back at this in the weeks to come I realise how lucky I am. In particular, I’m impressed at the speed of response. Tonight though, I’m oblivious and puzzled by the attention.
I know that my daughter Emma and sister Mary come to see me at some point and I’m sure I’m not a pretty sight.
There is still the coughing although it seems a little further away. I ask if I can be moved to another ward, any ward and I’m told that they’ve enquired and it isn’t possible. It’s a long night and the staff do their best but there seems to be a lot of raised voices and talking around the person with the hacking cough and after several hours I’m asked if I’d like a sleeping tablet to help me sleep through the noise. I mention the heart incident a little earlier and would this be safe, after reassurances I accept the tablet but only sleep for a little over half an hour then resume watching the hands on the clock drifting slowly around its face. I’m aware that I keep asking my assigned nurse (the nurse/patient ratio in this unit is one to one) to try to get me moved to avoid getting an infection from the guy with the hacking cough. My question is rhetorical as there is nowhere to put me and they’ve already done their best. In the weeks, months and years that follow and even now, I’m embarrassed that I kept asking the same question, I was like a man with dementia.
The anaesthesia coursing through my body may have been partially to blame but it doesn’t absolve me of the necessity to apologise and this I do, formally and unreservedly. I also hope that my personal nurse’s pregnancy went well and Christmas brought her the greatest gift of all, she deserved better than a patient like me and I am sorry that I gave her and the team such a tedious repetitive time when they were busy maintaining my life.
Being a Better Patient
The following day I’m transferred to the High Dependency Unit which is more open and looks a little newer but the mist of time and anaesthesia are affecting my memory. All of the staff in both of these units are bright, cheerful and highly skilled and I’m feeling a little better and significantly more confident. The nurse to patient ratio here is four or five to one but I don’t feel less cared for. It’s quiet in here and much more relaxed. The endotracheal tube is removed from my throat and I’m feeling significantly better although sleep comes easier and I drift in and out of light-sleep all day.
I’m not sure how long I’m in here, either one or two days. I’m then moved back to the ward next to the nurses’ station where they can keep a close eye on me.
Back to the Ward
By day four I’m able to get out of bed and walk always accompanied by my new pal the stand with a plastic bag usually part filled with a straw-coloured liquid. I’ve been told that’s a good colour for wee, it doesn’t want to be any darker and it certainly doesn’t need any blood in it. I’m also regularly tested for, well for whatever they test it for! Presumably sugar and proteins?
What I’m not aware of is, each time I walk, it’s monitored. Each step is a positive and there’s encouragement to move as much as is sensible. The balance is between exhaustion, wound repair and keeping the blood flowing in the legs to avoid thrombosis. I’m also given daily injections in the belly to help prevent clots.
The care is excellent with the exception of one night when the ward is staffed entirely by agency staff and my confidence levels are severely dented when I ask for some additional pain relief and am given ONE paracetamol. This is soon put right when the Acute Pain Management nurse comes to see another patient and I call them across. These guys are really on the ball and this one doesn’t take prisoners so, within seconds, I’m comfortable again.
On the days when the military staff are in the ward it is like a machine. The staff appear to be well looked after with time to complete whatever training and there is no excuse for not ensuring that any practical assessment that is necessary has time allocated to complete it. They’re also encouraged to take their breaks and the Charge Nurse Captain makes it her business to know what is happening in each of the side wards by patrolling them and asking both staff and patients about the current state of the individuals within. All of the patients like it when the military are in.
Catheters – Who Needs Them?
One of the registered nurses approaches to look at my notes and informs me that it is time to remove the catheter. I’ve wondered how they had threaded it into my penis in the first place and the thought of it being removed is accompanied by some anxiety. I’m asked to sit on the side of the bed and not to watch if I can help it. This is good advice. Then the nurse asks me what time it is and I look behind her to the wall clock and when I look down again it’s out and the nurse is packing the whole thing; tubes, bag and some bandages into a clinical waste bin. It feels great to have that apparatus out of the way and I begin walking further always passing the nurse station to tell them in case there are any issues. The first time I have a pee; however, is eye-watering. The soreness does diminish quite quickly though as it seems to dilute the effect the more that flows. Within a couple of wees I am back to normal but if you ever have a catheter, it’s worth knowing about the initial soreness as you have that first wee.
Exhaustion, more Exhaustion and Tears
There is clearly a lot going on inside me and the walk to the end of the ward and back would be accompanied by a long rest either on the chair or lying down on the bed. I was surprised at the lack of serious pain but never did get to grips with the complete and utter exhaustion.
Friends come and go throughout the week and the really thoughtful ones stay for ten minutes and leave, I am grateful for this and will ensure I thank them when I get back home.
The surgeon and team come to see me daily and show some enthusiasm for my improvement over the days. I’d expected more pain but the real issue is complete and utter exhaustion, I haven’t planned for that. I am also very tearful and ask the surgeon if this is par for the course. She reassures me it is and adds, “You’ll probably be like it for a few weeks”. I smile because I’ve always been emotional but this is just a little bit beyond that.
After about ten days I’ve managed to climb the stairs and this has been witnessed by the physiotherapist so the final obstacle is out of the way. Miss Hansrani is extremely pleased and says that I can leave. In fairness, she asks if I have people at home and would I be comfortable to leave. My mouth says yes and I even manage to sound enthusiastic; however, my head is telling me it’s too early. I ignore my head and go for it anyway talking to my family so that they can arrange continuous supervision for the first couple of weeks. I’m also surrounded by wonderful neighbours so I won’t be isolated.
The final significant procedure is the removal of the bandage which is done on the day I am to leave. I think the nurse has come to inspect it as normal but she explains that it needs to be removed. Now, this has me really anxious. The incision is a foot long and I have all sorts of visions of what it will be like under there. The nurse gently tugs at one end then sprays it with something that would make the adhesive soft and bit-by-bit she removes it with the minimum of pain and to my delight, it looks well on the way to repair. I have never thought that my bowels would fall out but neither did I expect it to look like it was nearly healed.
Anxiety now gone I’m dressed and ready for the lift home. I’m sad to be leaving the ward and I say goodbye to my fellow inmates followed by fond farewells to the Cleaner, the Coffee Lady, the Health Cares (especially the Health Cares), the Junior Doctors and the Nurses. I wished I could say goodbye to the Surgeon who is responsible for my life but she’s got a list and other people to patch.
It’s a sunny day when I leave and whilst being really, really sore, I’m on my way home.
If you are fortunate/unfortunate to have a serious operation the one thing that is difficult to warn you about is not the pain, that is generally well-controlled, it’s the profound exhaustion. As your body directs resources to rebuild itself the energy required to do the most mundane task is depleted and the shortest walk or exertion leaves you utterly shattered. One of the junior doctors tried to explain it to me but it needs to be experienced to understand. What I can say is this; it’s analogous to taking tablets for a headache, you don’t feel it going, it’s suddenly gone and that’s how this feeling vacates your body. One day, about six weeks after the op I’d walked around the small court where I live. It’s only a couple of hundred yards and I’d completed it with the company of a neighbour and when I reached my house, I realised I felt normal! That’s when I knew I was on the mend.
Would I make the same decision again? Oh yes, I really would.
To steal a phrase from Otto in Canada – ‘Life is Good’.
Many, many thanks are necessary not least to my wonderful daughters – Emma for none stop support and explaining things to me by taking questions to the experts around a busy working life, Vicky for coming 240 miles north to be here for me during recovery and getting me to the GP and then into hospital again as an emergency when I bled internally, Mary for all her support and all my good friends especially George Renwick who replanned so many walks to cater for my much-reduced capabilities in the first three months.
Most of all thank you to Miss Hansrani, her team and all the wonderful skilful staff at James Cook Hospital, plus Dr J B (Sheamus) Fitzgerald who’s attention to detail 20 years ago meant it was discovered and monitored in the first place and could be responsible for my life. Finally, I thank the people who fought for and delivered the National Health Service, may it continue un-privatised forever.
Feel free to share or comment, I love comments…G..x
There is a little hiccup in the first month and my daughter Vicky, who is a trained nurse and Community Matron in London, sees that I’m not looking good and suspects an internal bleed. Her diagnosis is correct and she gets me back into JC post-haste where Miss Hansrani confirms a sizeable haemorrhage that’s resulted in a large mass of coagulated blood in my abdomen. She’s reluctant to open me up again because of how weak I have become and puts me on some industrial-strength antibiotics with strict instructions to rest but ensure I do at least one short walk a day to stave off the thrombosis. The feeling of helplessness is intense as I realise that ‘where-we-are’ is ‘where-we-are’ and there is no reversal. I need to get better or die and I do like the idea of the former so do exactly as I’m told. The antibiotics combined with the haemorrhage make feel like crap for two full weeks but the upside is that when I stop taking them and the blood clot starts to disperse it’s like a heavy weight has been removed and my steps become lighter and easier.
The drugs and nursing care from Vicky and Emma deliver a complete recovery and the following months and years see me walking over 8,000 miles on the Yorkshire Moors, the Dales, Scotland, in Spain, Portugal, Bangladesh, Malaysia and France and I’ve been able to enjoy many nights and holidays with friends and family.
If I lived in the USA, the cost of the operation and care would have bankrupted me. Thank you, NHS and all that work within it. Life really is good.
Here’s a snap of the results of that gifted lady and her team’s endeavours…