Having a Coronary Artery Bypass Graft in the Cardiac Surgery Unit of Bristol’s Royal Infirmary in 2006
My story is worth telling only because I think it is fairly typical of the experience of the majority of those who had heart surgery in Bristol this year. It is dedicated to everyone I met, and particularly to the outstanding staff who work there. All names have been changed for it has not been my intention to praise or blame individuals, but to convey what it all felt like. Here then is my story. It is not a medical treatise, but a subjective, patient’s eye view of what having a “triple by-pass”, a “CABG” is like.
Lunch in Bristol
Having driven up from Somerset, my wife Elizabeth and I decided to lunch at the Rainbow. Nothing fancy. It is a small Clifton eatery virtually unchanged from hippy days in the seventies when Elizabeth and I took our little girls there after an exciting morning shopping or a walk on the Downs. Now they are adults and we have a grand-daughter. We reminisced about the past, brightly discussed the food and never mentioned what we both were thinking – that this could be our last meal together.
At two in the afternoon we entered the hospital, tugging along a small case and grimly clutching my official referral letter . The Bristol Royal Infirmary is an unlovely piece of concrete brutalism erected uncomfortably in those same seventies on the side of a hill near the city centre. It seems to be a perpetual building site and finding parking is a nightmare. First impressions of the crowded lobbies and lifts did not lift the spirits.
Ping. Level six. The lift deposited us outside the Cardiac Surgery Unit. We went into Ward Five A. On the left a row of chairs stood against the wall. Some were occupied. On the right there was a long reception desk behind which nursing staff had congregated. They were busily filling in record forms. By the entrance a middle-aged woman receptionist sat behind a computer monitor. She looked tired. Still, she gave us a friendly smile and said, on looking over my letter, “I’ll need to check all your details to make sure we get everything right.” She then surprised us by getting up from her chair to come around to my side of the desk so she could set up a chair for me to sit on while she questioned us. She was pleasant and thorough and made quite sure all the relevant telephone numbers were down so Elizabeth could easily be contacted if necessary. We both felt reassured.
One thousand four hundred and eighty-five.
A few days earlier I had looked up Cardiac Surgery at the BRI on the Internet and had read the latest press release. It was then I had learnt that in 2005, the unit had treated 1,485 patients. Frankly I was staggered for this seems a truly awesome number. As I was told by nurses a ward could have some six to eight scheduled operations a week plus one or two unscheduled emergencies. Bearing in mind that each operation takes between three and four hours and the surgeons normally do one in the morning and one in the afternoon, this makes for a very demanding workload on a production line of life and death operations. In addition the press release pointed out that in the Hospital Doctor Awards for 2005 the Bristol Unit had been awarded the accolade of Surgical Team of the Year. Impressive.
My situation on admission was fairly typical. Almost everyone coming in will have had a heart attack quite recently, or like me, some months earlier. A heart attack is set off by a clot of fatty cholesterol breaking from an artery and blocking the flow of oxygen to the heart muscle. Deprived of oxygen a part or the whole of the heart muscle ceases to work – for good. If the damage is too extensive, you die. If reached in time it is possible to inject into the heart a strong anti-coagulating agent which will limit considerably the area affected. However, it might also kill you and it cannot reverse the damage already done. It all adds up to quite a scary scenario.
Most of us coming to the BRI would have found having a heart attack a complete surprise. Others would have had the tell tale signs of angina – breathlessness and discomfort in and around the chest. For me the attack had come out of the blue – totally unexpected for I was fit, had jogged three miles the day before and was not at all overweight. When the strange chest pain hit me however, I reacted fast and took myself straight to the Wincanton Health Centre. There the practice nurse had me seen immediately by a GP and they immediately called an ambulance from Yeovil. Two excellent young women paramedics had then arrived who put me in the ambulance and gave me an ECG and offered me the choice of having the anti-coagulant Tenectoplase and I had accepted it and had been “thrombolised”. The ambulance then careered bee-baaing along the A303 to the Cardiac Care Unit in Yeovil Hospital some twelve miles away. There I had been kept for five days and very well cared for by consultant Dr James Ho and his excellent team.
On discharge I thought rather over-optimistically that I had got away with minimal damage despite Dr Ho’s carefully balanced words of warning that it was too soon to tell. Two months later however, when the heart muscle had healed as much as it could, the results of a treadmill test revealed a serious irregularity in my heart beat. As a result I was sent to Taunton for an angiogram. Here a tube was inserted into my leg artery near the groin and then pushed right up into the heart. Once there dye was squirted through the tube into the heart‘s arteries. This incredible procedure is, perhaps surprisingly, not painful and is carried out under local anaesthetic in a day surgery. Dr Ho came from Yeovil to oversee the procedure and the TV monitor showed what even to my untrained eye looked suspiciously like blockages. He immediately came over to me.
“I’m afraid John, my news will come to you as a bit of a shock.” he told me. “You will remember I explained the angiogram could give us three possible scenarios. The first is it might show the heart attack caused relatively little damage to your heart muscles and your heart arteries are clear. If that were the case all you would need would be to keep to the medication we subscribed for you in Yeovil. The second is that it might show blockage in one or two arteries. That could be treated here in Taunton by inserting one or two metal tubes or “stents” into the arteries of the heart at the affected points. That would have meant an operation rather like this angiogram called an angioplasty. I am afraid however that you have three rather badly blocked arteries and that will mean, in my opinion, and subject to agreement by the surgeon who I usually work with, Mr Fellini, that you will need to go to Bristol for heart surgery and have a triple bypass.”
He was right. This did come as quite a shock. To check just how serious this was I then asked him what would happen if I said that I would prefer not to have the operation. He shook his head, laughed quietly and said, “I’m sorry John, but despite medication, in the next few months you would probably have another heart attack and that would either kill you or leave you too damaged and weak to undergo a heart bypass operation. As it is you are comparatively young, you seem fit and your heart muscle is relatively undamaged. This means you should recover well and you should be able to expect five, ten or even more years of active normal life.”
Five years for someone of sixty-five did not sound so good, but ten or more did, certainly given the alternative. Clearly then longevity was not something he could predict accurately and the range of possible outcomes was wide. This certainly would take some coming to terms with. He then continued, “Yes, I can see, this must all come to you as a shock. I will give you some time to think about it and then when this catheter has been removed and you are dressed and comfortable, I will come around again and we can talk it through and I will explain in greater detail just what is involved, then I hope you will see there is quite a lot to feel optimistic about.”
That is exactly what he did, so by the time I left Taunton later that day I felt surprisingly calm about the whole thing. He also explained that the next stage would be that on his recommendation I should see the surgeon he had mentioned from Bristol, Mr Fellini, when he next visited Yeovil and that he would interview me and make a final decision. If, as was “99% certain” he agreed that I needed a triple bypass, I would be put on the Bristol waiting list to be operated on within three months of that date. First though I had to wait for the appointment – for five weeks. “I wish all our patients could be dealt with within three weeks, but it is just not possible,” he said. “If you have any doubts about your health though, or any symptoms, do not hesitate to get in touch.” I had no symptoms at all and felt almost scarily well, so I just had to wait.
Weeks later as promised I saw Mr Mario Fellini in Yeovil. By then I had learnt from the internet that the Cardiac Surgery Unit at Bristol was lead by Professor Frederico Garibaldi. He headed a international team of eleven consultant surgeons. Two of the other consultant surgeons were also Italian. It appeared also that Mr Fellini had in fact specialised in developing the technique now used in most cases in Bristol of doing the operation “off pump”, that is without stopping the heart and the use of a heart by-pass machine.
Meeting Mr Fellini was memorable. I went along with Elizabeth, and for complicated family reasons, my grand-daughter of two whose presence did not phase him. He is a tall, imposing man, with a direct, gentle manner and an attractive accent. He was very good at listening, did not rush us and answered every question we could think of in a straightforward way. He explained carefully just what the angiogram had revealed and said he completely agreed with Dr Ho that a triple bypass operation was needed as without it my prognosis was not good. He explained that if I had the operation there was a 3.4% chance I would not survive, but a very high probability I would come through well and that once recovered could expect “many years” of active life. I would now, he explained, be placed on the official waiting list and should be operated on within the next three months. It could be sooner if there were gaps or cancellations or if I developed any new symptoms, or it could be towards the end of that time if they had a heavy load of emergency cases. That did not make us happy for three months seems a long time to wait for an operation once one has been diagnosed as having a life-threatening condition and one which could suddenly deteriorate, but if I did not qualify as urgent or an emergency I could see I would just have to wait.
In fact only a couple of weeks later a phone call came from Bristol telling me that a slot had come up and Mr Fellini had been able to schedule a time for my operation on the next Thursday morning – which was in just four days time. The next day this was confirmed by letter and I was also sent a very useful booklet (A Patients Guide to preparing for Heart Surgery at the BRI) spelling out just what one needed to know, to pack and to expect. I was very glad the wait in limbo was over, but not without some feelings of apprehension.
Wednesday. On the Ward.
Immediately after being signed in by the reception clerk, we were approached by a smiling, enthusiastic man with an official-looking identity tag. He looked about seventy. He explained that he was a volunteer who had undergone the operation himself and that together with a team of others he came regularly to the hospital to give those who had just been signed in “a patients eye view” of what to expect. He had his operation six years ago and said he had never felt better than he did now. He emphasised that while there is discomfort, there is no need to fear any serious pain and that the way everyone treated him had been “just wonderful.” We were then introduced to a couple of other equally enthusiastic volunteers with similar stories. This came across as impressive not only because they were prepared to give up their time to share their experience with me, but also because it showed self-confidence on the part of the medical staff to “let loose” former patients to talk to us in this way.
No sooner were they finished when a nurse arranged I go down into the bowels of the hospital to have a chest X ray and on returning to the unit I found several people were ready to see me. The first was Dr Mike Cartwright an incredibly young looking English doctor who would be my anaesthetist. He told me he was a registrar and asked when I had last had a general anaesthetic. When I told him how debilitating and unpleasant that had been and how sick I had felt afterwards, he assured me that the last few years have brought considerable advances in his craft and the after-effects now should not be as severe. He also checked for any capped teeth (which could be damaged) or dentures (which should all be removed) as he would need to put an oxygen tube down my throat and that when I woke up it would probably still be there, “But not for long,” he said.
Next I was taken to what looked like a rather “state of the art” new ward with four gleaming beds, towers of complicated machinery and a television monitor and telephone for each on a long, swinging arm. There I was asked to undress and given an electrocardiogram (ECG) to measure precisely how the heart was functioning followed by the first of an almost incessant number of tests of my blood pressure and pulse rate.
The next visitor was Dr Presad, the surgery registrar who would also take part in the operation. He was very keen to examine my arms and legs and the state of my veins. Finally Mr Fellini came and checked everything very carefully himself. He confirmed that the operation would take place at 8am the next morning, ran over the potential risks and advantages of what he was about to do, and had me sign the official form giving my consent. Elizabeth then left to stay with some of our friends, and I was alone on the ward with one other patient, an older man in his seventies. We did not feel like chatting. I had supper, worked out how the TV and telephone operated, and received phone calls from Elizabeth and my daughters in London. I felt tired, but surprisingly calm. I had written letters to Elizabeth and the girls in case I never came around and had made sure my will was up to date, and there really seemed to be nothing else I could do but face what was coming with what equanimity I could. I was definitely helped to do this by the night nurse, a softly spoken girl from the Philippines, who was clearly used to preparing patients for the coming ordeal and had a straightforward, gentle manner. She said I should take a thorough shower using a special anti-septic to reduce any chance of getting or giving anyone MRSA and use an anti-septic cream to put in my nostrils. She also went over just what I should expect in the morning.
I slept deeply and without interruption, but woke early at around six and was able to sit and meditate as I do for half an hour. The nurse then arrived and quickly and expertly, knowing exactly where the incisions were likely to be made, shaved my lower arms, legs and my chest. It was strangely comforting. She then sent me off to have a final shave and another very thorough shower and gave me a theatre gown to put on afterwards. She also told me to pack all my belongings in my bag as I would not be coming around in this ward. On getting back from my ablutions she gave me my pre-med, which she said was a strong sleeping tablet. By then it was seven am. At eight precisely a porter arrived with a stretcher. I was still awake but drowsy and the two of them moved me on to it and pushed me the short distance to the operating theatre where I was greeted by anaesthetist Mike. He gave me an injection and I was out.
Thursday. Under the Knife.
My little red book had told me, “A coronary artery bypass graft (CABG)” (referred to by everyone as a cabbage) “is an operation to bypass the narrowing or blockage caused by cholesterol building up in the walls of the coronary arteries. A bypass graft is sometimes a vein taken from your leg. One end is stitched to the aorta (a large artery close to your heart) and the other end is stitched to the coronary artery beyond the blockage. In some patients the internal mammary artery is used as a graft. This lies within the chest wall behind the nipples. One end is detached and stitched to the coronary artery behind the narrowed segment. Occasionally an artery from the arm is used. In some patients the procedure is carried out without the use of a bypass machine. This is a common practice and does not affect your care or recovery.”
Not surprisingly this puts it all rather gently. In fact by the time I went into the theatre both doctors and nurses had explained what was going to happen in rather more detail. Doing this actually makes everything easier to handle as there are no nasty surprises when you come round and they get to work on you. As regards the operation itself, they enter the chest by cutting right through the breast bone (sternum) from top to bottom and pin back each half with its attached ribs for the duration of the operation – so exposing the heart. The artery that is “harvested” from the left arm is taken from between elbow and wrist and the leg vein from between the knee and the ankle. These are examined for suitability before being used by the surgeon for the grafts. Next some clever cutting and sewing is done to disconnect the mammary artery from the left breast and connect it instead to the heart. The measuring, cutting and stitching involved is of course extremely delicate and critical. Your life is literally in the surgeon’s hands. The role of the anaesthetist is also crucial, responsible as he is not only for keeping you under, but for seeing to it that you continue to take in oxygen through the tube he inserts. He also monitors a flow of other vital medications into the blood stream.
In Bristol around 60% of CABG operations are done “off-pump” that is without stopping the heart and replacing it with a blood pump. This has advantages in reducing possible complications and speeding up recovery. On the other hand working on a pumping heart requires the greatest degree of skill, so it was reassuring to know that Mr Fellini is a leading specialist in doing this. Of course if there are complications the bypass pump still needs to be used and always needs to be available. My operation however was “straightforward” and “off-pump.”
The aim is “complete revascularisation” the proper pumping of blood to all the areas affected by the blocked arteries and when this appears to have been achieved the incisions in the arms and legs are neatly sewn up with dissolvable stitches. Two wires are then placed alongside the heart. They will be attached to a temporary external pacemaker. The ribs are then put back in place and the two sides of the breastbone securely wired together so no coughing or anything else could break the join open. The chest incision is then neatly sewn up leaving two thick tubes in place below the lungs to act as drains for any blood or fluids that may have accumulated during the surgery.
Thursday. Intensive Care
Around lunch time I was then moved from the operating theatre to the Intensive Care Unit where I was kept fully anaesthetised for several hours while a battery of tests and interventions were carried out to make sure I was breathing and my heart was beating regularly. Elizabeth was called in at about 4pm in the afternoon and I was allowed to come round. My first memory was of being aware of the oxygen tube in my throat. Elizabeth tells me there was also a monitor that beeped loudly if I failed to breathe and she was told to tell me to do this. I was then told to concentrate on my breathing to stop the beeping myself, which apparently I did – although I have no memory of any of this. That evening I came round a bit more and there was Mr Fellini standing beaming at the end of my bed. “It has gone very well John”, he said and I waved back. I then again lost consciousness for many hours during which time the breathing tube was removed from my throat, an oxygen mask replacing it, and I was moved from the ICU to the High Dependency Unit.
Friday. High Dependency.
The HDU ward I was in contained only five beds, in these were two women and three men. At all times, day and night, there were four nurses on duty and they were kept pretty busy. The ward was large and there was a good deal of space between the beds, and there were a couple of chairs. Curtains ran around each bed and were always used to give complete privacy when needed.
I was now conscious for much of the time and was able to take in my situation. I was aware I was not a pretty sight. I was breathing through an oxygen mask and two thick rubber tubes were stuck into my stomach below the lungs. These were there to drain away the blood and fluids leaking out as a result of the surgery and they accumulated into a large plastic bag of evil looking red-black liquid. They caused no pain. A catheter had also been inserted to drain away urine as it was produced into another bag. Again this caused me no discomfort, though I was lucky for later I saw another man who found his catheter very painful. Both these bags were regularly emptied by the nurses and the contents carefully weighed to see how much fluid I was gaining or loosing. In fact one initially gains weight from fluid.
Sticking into my neck and connected directly to the vein was a large needle with some three valves attached to it. Through these syringes of potassium and adrenalin were administered to keep the balance needed in the blood at the correct level. The third valve I understood was there for “emergency purposes” if some special stimulant was needed because the heart was faltering. The potassium and adrenalin level needed was judged by having a line attached to a vein in my right wrist from which syringes of blood were drawn every hour and analysed. Again, this was not painful and all this was quite easy to accept because I had been told to expect it before the operation. The neck implant did however mean turning my head to the left was impossible, so I mainly looked straight ahead.
Strapped to my chest now there was also an external pacemaker. This monitored my heart beat and if the rate fell a bit low it sent prickly electric charges down the wires into my heart. These were not pleasant, but I was lucky in that I had no more than a couple of minor tweeks. It was encouraging however to know it was there. At this stage also a machine automatically measured my blood pressure every hour and when it did I needed to have a finger held in a clip which I think measured my heart beat. Less pleasant were the sharp pains I felt on moving either my left arm or left leg which also were rather swollen.
A nurse was never far away, always ready to come over if called, and every procedure was done gently , skilfully and confidently and absolutely everything was recorded and checked. In addition I was provided with a button to press in my right hand. This was connected to a line in my arm which injected morphine in carefully measured doses. It was explained that by pushing the button one could never give oneself too much, but it meant relief from any strong pain was almost instantaneous.
Kevin was in the bed next to me and we had both been operated on at the same time, though with different surgeons. That afternoon while Elizabeth sat with me he was visited by his wife, daughter and granddaughter. It quickly emerged that he was a Sun reader with a strong Somerset accent and loud opinions, describing the Indian nurses who made up part of the shift as “foreigners”. Like me he was not very comfortable for the one thing that caused us all some discomfort was the fact that the oxygen tube that had been removed had gone down right through the vocal cords leaving us hoarse and with sore throats. We were also told to expect a wracking cough and that we should need to cough up quite a bit of mucus and it was important we got rid of this and did not swallow it.. Whenever we had a cough we were almost cheered on by the nurses to try harder as the more we could bring up the better we would feel. Coughing was not that easy though for not surprisingly after all that had been done the whole of my chest area around the heart felt very constricted and quite painful. Kevin however I could hear was having a much harder time of it than I was. That night I slept hardly at all, waking up either when the nurses came to test, check and inject, or to cough. In addition I could hear Kevin coughing violently, expectorating and complaining that whenever he fell asleep he had awful hallucinations.
The night effectively ended just after I had finally dozed off and was getting some sleep when I was woken by one of the night nurses and told I should get out of bed and sit in the chair next to it. I could not believe my ears. “What time is it?” I asked. “Five-thirty,” she replied. I complained that this was ridiculously early, but she was very insistent. “You will find you can do it” she said, without offering to help in any way, “And then you will feel much better.” I found that hard to believe, but on reluctantly doing as I was told – for she remained very insistent – I found the immediate result was I did feel better. I guessed that this was because being in an upright position it was easier for the waste liquids below the lungs to drain away. Still I felt she had been unnecessarily heartless, should have given me some physical support as I was justifiably afraid that if I tripped over all the bags and tubes there could have been a disaster, and she should have explained things properly, and that five-thirty really was ridiculously early. I complained to one of the other nurses later and she agreed I had been insensitively treated and such an early start did not happen again.
During the day the oxygen mask was replaced by a thin oxygen tube one could arrange under the nostrils. This was much easier to deal with and could even be dispensed with for short periods. Then the catheter was removed and the blood bag detached. The external pace-maker went and I was encouraged to spend most of the day sitting by my bed in a chair. I knew what was coming next. Helen the day nurse approached smiling cheerfully.
“Well John, you are looking much better today. I think it’s time for you to have a go at going for a walk.” She then gave me a folded towel to press against the wound in my chest which she said would make it easier to cough, and a plastic cup to cough into. Then taking my arm and making encouraging noises, she helped me walk the length of the ward and back again, pausing for the occasional rather disgusting coughing session – for which she praised me enthusiastically. Despite some pins and needles in the leg I found this walk surprisingly easy to do and a great boost to my confidence. I was definitely feeling better and making a contribution towards my progress. As I passed the other patients we all smiled and waved at each other as at different times that day we were all put through the same routine.
At first I think we all looked extremely weak, but after that first walk we were told we could get up and try walking through the wards and down the corridors for ourselves whenever we wanted to as this would improve our circulation and speed up our recovery – so long as we did not overdo things. Free of catheters we were also encouraged to walk to the toilet on our own as soon as we felt ready. At the same time there was always a nurse keeping a sharp eye on us as we staggered around. Again after being totally dependent it felt good to do this and everyone started to look better and more alert.
That afternoon Elizabeth brought my two daughters and my grand-daughter to see me. They had just got off the coach from London and were obviously shocked to see this battle scarred figure with tubes, lines and drips and an odd croaky voice, still it was wonderful to see them. They did not stay too long.
That evening the night shift consisted of Ingrid, an extremely pleasant and efficient young German nurse who loved canoeing and living in England who worked mainly with me and three nurses from Kerala in India. Again they were all kept pretty busy with their almost endless rounds of giving us injections, checking blood pressure and pulse, and helping us with the coughing. Kevin had one of the girls from Kerala working mostly with him and again he had some really unpleasant prolonged coughing fits. She could not have been more sympathetic and helpful and seemed to know just what to do to get him comfortable. In the morning I asked him how he was feeling and he said, “I’m getting better. Actually had some sleep. You know John, that nurse last night, she was really excellent.” I wish she had heard that.
That second night I too actually had several hours of good deep sleeep and found my chest had cleared appreciably and I could breathe more deeply, despite the discomfort. Ingrid let me remain in bed until I was properly awake in the morning.
“So how are you feeling then?” she said.
“I’m really feeling much better,” I replied.
“That’s good. Do you think you would like a shave?” she said, and all hopeful I thought she was offering to do it for me.
“Yes that would be great,” I replied.
“You know John, really, I think you are now well enough to try for yourself.” she said with a big smile. So I did, and felt great.
As it was the week-end they decided not to move us from the High Dependency Unit which was nice as it was just becoming familiar. I got up and walked around the wards and corridors a couple of times and talked a bit with Kevin and Glenda who was in the bed opposite. Kevin told me he was only fifty-two and had suffered a severe heart attack which had brought him straight to the unit as an emergency case from Chippenham. Unlike his family he was not obviously overweight and like mine his attack had come as a total surprise. He was now feeling and looking much better and was itching to get home. Glenda in her late fifties had also suffered a severe heart attack and had been taken as I had been to Yeovil where she had been in the Coronary Care Unit for three weeks until she was stable enough to be brought to Bristol by ambulance. She also was amazed at how quickly she was feeling better.
There was a bit more time that day for Elizabeth and I to talk to the nurses who told us how they were regularly rotated between Intensive Care and High Dependency (and I think they said the admission and discharge wards) so they were able to see the process as a whole and how the whole unit works as a team. They also emphasised that the decisions about treatment and particularly when it was right to move one on to the next stage, were taken collectively. As nurses they said, they could express their opinions and if necessary criticise or differ from the doctors until they reached agreement. They also told us that once a quarter they had a day when all the nurses on the same grade met to discuss how things were working across the whole unit and how things could be improved. They then all went out to lunch together (at their own expense) which was much enjoyed.
Each of my perambulations left me feeling a bit stronger, but I was still completely whacked when I got back to bed and my chest was still pretty sore. In the afternoon Elizabeth again visited with the girls who found their second visit less scary. They then caught their coach back to London and Elizabeth returned to sit with me until half past eight. It was really good just to have her sitting there quietly and chatting about everything that was going on. I thought it must be really hard to go through this alone with no-one to come and visit as it seemed was the case for quite a few.
Getting ready to go home. Monday, Tuesday and Wednesday.
After another improved night the needle attached to my neck artery was slipped out and on Monday morning I was moved back to Ward Five A where I had been on my first night, though this time there were three other men there, two awaiting an operation, and a third who was brought in a bit later.
Opposite me was Hamish who looked and sounded like Donald Sutherland at seventy-five. Originally from Scotland he had brought his bride down to Bristol in the fifties and had forty years of happy marriage, but no children. Two years ago she had died of cancer leaving him on his own with severe angina. He had been a semi-professional billiards player and regaled me with tales of playing with some of the great billiards pros before they became famous. Social Services had sent him a carer to look after him when the angina had disabled him, and after a year he had married her. She was a jolly Jamaican lady with a bright red wig and a daughter who had come over and joined them and was now doing well at university. On getting him in to hospital his consultant had diagnosed that in addition to his heart problems he also needed the veins in his neck dealt with as they were calcified and so he would be having a very complicated operation which would need two teams of surgeons. He was still waiting for this to happen when I left.
The third patient was an emergency coming straight in from the Intensive Care Unit after his operation as there was no space in High Dependency. A tall, strong-looking young man in his thirties, he was still not conscious, but his young wife was eager to talk and said that his heart attack had been a complete surprise and that he had been rushed to Bristol in an ambulance. On arrival they said he had got there just in time for them still to be able to operate and when they opened him up they found that as well as needing a triple by-pass, he also needed to have two of his heart valves replaced. Very tough.
For me though the focus had changed and the nursing team that took over made it clear that everything now was directed at seeing to it that I was ready and fit enough to go home. At last the rubber tubes were removed from my stomach. They slipped out with little discomfort. I was however, pretty constipated, an almost inevitable consequence of the anaesthetic and pain killers, and daily doses of laxatives had achieved nothing. Dr Presad said that until this was resolved I could not be let go. Apart from that it seemed he thought I was progressing well and it might be possible for me to go home on Tuesday. That morning I was also given an ECG by an elegant girl from the Czech Republic who told me that this was to measure more accurately the post-operative functioning of my heart and that it seemed all was well.
Next the nurse working with me said that I needed to be given a final X ray before the decision was taken about when I could go home. This turned out to be the most unpleasant experience in my whole stay for I was taken out of the unit in a wheelchair in my pyjamas and down to the X ray department on the ground floor by a porter who was then called to do another job and I was left abandoned in a very cold lobby for more than an hour. Eventually I was given the chest X ray, but then I had another long wait until eventually another porter was sent to take me back to the ward upstairs. By the time I got back to the unit I was very cold, exhausted, and frankly thoroughly miserable.
That afternoon after Elizabeth left me, I tried walking around the wards, but my chest was quite painful and I coughed a lot and was still blocked up. I was then given one of the endless blood-pressure tests, but this one showed my blood-pressure was suddenly rather too low. It all added up to making me feel that I was not ready to be tipped out to go home where there would be no quick back-up if things went wrong. I also had absolutely no appetite and found eating any of the food brought to me almost impossible.
Serving us food was the responsibility of a team who also brought us drinks and spent much of their time cleaning the wards, toilets, bathrooms and floors. They were a mixed bunch of Africans from Kenya and Nigeria and white Bristolians. Without exception they were extremely polite and pleasant, bringing us menus which gave us quite a lot of choice a day before being needed. The food looked quite good. Some of them also had quite a flair for irony and humour which went down weel with us. I had a chance to talk to one of the Bristolians. He was a fit looking ex army man with the tattoos to prove it. He had been doing the job for three years and said this was by far the best “civvy” job he had ever had for he felt he was doing something worth while. When sweeping and cleaning all the team I saw in action were very thorough. Toilets and bathrooms were done every two hours and they were very well aware of the dangers of MRSA.
Tuesday however started well with the enormous relief of movement in the lower reaches after which I took myself off for a shave and a shower which greatly improved my morale. When Dr Presad came around I greeted him with the news, however he agreed that I was not quite ready to go home until my blood-pressure could be seen to have stabilised, and said that I should stay in for a further day. I was relieved.
That day I walked around as much as I could and saw Kevin who had also been told he could go home on Wednesday. Our overall opinion was that we had been through an amazing and challenging experience, but had been extremely well treated. We wished each other good luck. A bit later I even got dressed and went to the hospital cafeteria when Elizabeth came to visit. There we sat drinking weak coffee surrounded by the mildly depressing site of rather a lot of very young, very overweight Bristolians.
On returning to the ward and getting back into bed I was suddenly confronted by the splendid figure of Mr Fellini in a beautifully cut black suit made of some rather special cloth. With it he wore a fine white shirt and a red tie. An impressive example of cool Italian style.
“Tell me John. How are you feeling?” he asked. I said I felt a bit worried about the sharp pains in my chest and he examined me carefully and got me to cough.
“The discomfort is to be expected, but I think everything is in fact quite normal. All your records show that you have in fact been doing very well. Your blood pressure is fine now and I am sure you are ready to go home tomorrow. Tell me, how well have you been eating.?”
I replied that despite the food looking quite good, when it came to trying to eat, I found it almost impossible as my sense of taste was completely messed up and I had no appetite at all. He agreed that this often happened, “And it is difficult for us to provide you with really good food here,” but as soon as I got home he said, I should eat as much as I could to build up strength.
“All that remains is for the pharmacists to make up your drug prescription, and the physiotherapist to check that you are well enough to go up and down stairs, and to give you some advice on exercise.” he said. He also told me that I would see him once more when I came back to be checked over in Bristol in six weeks time. I thanked him for all he had done and said I thought all the treatment I had on the unit had been extremely good. Again I felt that here was someone who really cared about his patients.
Almost everything was done now. A pleasant, efficient young woman from the Scottish Highlands who turned up to check out my now voluminous record folder turned out to be the pharmacist and she promised that my package of medication would be delivered to the ward first thing on Wednesday morning.
The Physiotherapist then arrived. A tall, jaunty, athletic looking young man, he wore a dark blue outfit and – as a badge of office it seemed – a stethoscope around his neck. He took me and a small frail looking woman of about eighty, off to a stairwell. First he checked that there would be someone at home to care for us during the first week. (I had Elizabeth and this lady had her son) then we were simply asked to walk up and down a flight of stairs unaided. We chatted a bit and the elderly lady seemed quite a character describing with enthusiasm how she had lived in the same terraced house in Bedminster for over forty years. To my surprise she managed the stairs in an amazingly sprightly way, surprising as a few days earlier I had seen her staggering around the ward looking very weak indeed. Now she announced that she felt so well she thought she needed a toy boy with a motorbike to take her for a drive around Bristol! That sally floored the physio who laughed nervously.
Wednesday morning brought a final examination by Dr Presad, who after a nurse had failed to get them to move, nonchalantly and painlessly drew the five inch steel wires implanted for the pacemaker out of my chest.
“Incredible technical skill!” I enthused. He smiled modestly.
“I’m sure he’d like you to think that,” said the nurse, “But I think they slipped out so easily because I loosened them up for him first anyway.” Much hearty laughter. She then very neatly removed odd bits of surplus stitching from my rapidly healing wounds with a scalpel and drew the last needle out that was still stuck in my arm “in case of emergency.”
We also discussed aftercare. Basically Dr Presad said I should be fine at home, but if anything about the wounds or my heart beat worried me, I should go to my GP. In addition Dr Ho in Yeovil and the Cardiac Rehab Dept there would be notified and I would be hearing from both of them after six weeks.
The medications duly arrived together with a letter for my GP, final farewells and thanks were said and I was free to dress and go.
Elizabeth went off to get our car and a porter was called to take me in a wheel-chair down to the entrance so I would not have more than a few yards to walk. As he pushed me he told me how he loved his job which he had been doing for the past three years after a life-time of factory work. He said he had never had a job that felt so worth doing. He said he also thought the B.R.I. was a wonderful institution and that every day people told him how well they had been treated. “It‘s a pity,” he said, “That‘s not what you read in the press.”. I thanked him and said that I too had been given wonderful treatment. I then got up and walked out to our car while Bristol’s traffic poured past, as ever nose to tail. An hour later we were home in Wincanton.
The words that keep coming to my mind when I look back on my experience are “amazing,” “inspiring,” “ unforgettable,”
It was amazing because I had absolutely no idea of the huge numbers involved in having heart surgery and am quite sure that outside medical circles people are completely unaware of the scale of what is going on and that this year probably 1,800 people will come to Bristol for heart surgery, not to mention similar numbers going to other centres around the country, and that around ninety-six percent of them will receive a new lease of life.
It was inspiring because one might think that such a massive production line could result in those who work in it becoming blind to the bigger picture, only seeing their own jobs as important, and start treating their patients in an uncaring impersonal way. I never saw this happen, neither did I see one group of professionals treat members of another badly. Instead there seemed to be a real sense that everyone on duty in any one place was part of a team and that everyone depended on the work of each other. In fact what I experienced was a calm, purposeful atmosphere which seemed to pervade the entire unit from the time one was admitted to the moment one left for home. I am sure that was no accident.
It was inspiring to see such a wonderfully varied collection of people drawn from right across the globe all working so well together. What was more everyone – doctors, nurses, cleaners, technicians etc – treated us patients as people, people who deserved respect, understanding and encouragement in recognition of the fact that we were all being put through a life-threatening and extremely challenging ordeal, an ordeal which could result in death or catastrophe for any one of us at any time – if anyone let their eye wander off the ball.
It was inspiring to see staff morale so high. It was quite evident that staff at all levels took pride in what they were doing and acted with sensitivity, confidence and skill. This had a profound effect on our morale as patients, encouraging us to work actively towards our own recovery and take responsibility for ourselves as soon as we could. If that had not been there at any point I am sure the remarkable confidence, courage and cheerfulness which I saw in so many fellow patients would have evaporated into fear, uncertainty and anger. What that might have done to the mortality rate on the unit I would hate to think.
It was unforgettable for what sticks in the mind as one who has gone through it are not the medical details so much as the people one met and how they made one feel, be they surgeon, waiter/cleaner, night nurse, day nurse, technician, porter or fellow patient. Each had their role to play and story to tell in the unfolding drama that was life on the unit. Everyone who was considerate and sensitive contributed to our well-being and healing. Reflecting on these stories and meetings I could not but be aware that what the unit is really about is giving people back their lives, of giving us the opportunity to continue with our interests, achievements, joys and relationships, to give people back to their families, friends and those around them.
This did not mean of course that there were no irreverent jokes, no black humour, no flirting or fooling around, and dull life would be without that, but never that I saw was such banter at the expense of remembering the bigger picture, that a battle of life and death was going on, a battle that I overheard one doctor say continued “remorselessly and without let up.”
I saw no doctor behave in a stuck up, superior or unfeeling way or not be prepared to listen which surprised and impressed me. In a week of being nursed intensively, I only had one occasion when I thought I was treated insensitively by a nurse, and only one occasion when I felt I had dropped out of the loop and been forgotten (the X Ray experience) Against those I had so many positive experiences where I was treated really well.
I hope that enough care is taken of the cleaners who also brought us our meals and drinks, not only to see that they are properly paid, trained and managed, but to see that they are helped to feel valued and appreciated by other staff – for again if they are not – the achievements of everyone else could so easily be put at risk.
Reflecting on how the whole process had been planned and put together made me aware that here was an incredible managerial achievement. Whoever has overall responsibility, has produced something truly amazing. This is the NHS at its very best, delivering a life-saving service of enormous complexity (and no doubt enormous cost) to those who need it regardless of their wealth or status without charge at the point of delivery. What stronger affirmation could there be of that fundamental respect for human life our society professes it is built on.
I have tried to describe what was done and why in the right order, but a general anaesthetic can play some strange tricks with perception, memory and the passing of time, as well as with taste, appetite, bowel movements, etc. etc!
4 December 06.
My operation was on 2nd Nov 2006.