Dancing with Doctor D - Preface
30 July 2021 | A morality play in three acts.
In consideration of the rapidly waning concentration spans and short-term memories of our loyal readership, this woefully edited post has been split into three parts. To facilitate reading this departure from the norm, the natural order of blog posts (most recent first) has been reversed. You can now start with this preface and follow on to parts 1, 2 & 3 as if you were reading something normal, like a book.
You do remember books, don't you?
If you can't see the last post, click on 'older' on the bottom right.
Dancing with Doctor D - act 1
30 July 2021 | Ouverture – Allegro Crescendo
Well, it's been an interesting couple of days. Twice in seventeen hours, I've felt a closer acquaintance with death than I have in my previous 72 years. Whereas before we would just nod on the stairs, now we are on positively intimate terms (for Brits). You know the sort of thing:
"Morning, Mr Carmichael."
or in our case:
"Morning, Mr Newbury."
Hands up those who had even considered the possibility that Death was a Brit? Personally, I think he's Welsh.
On Thursday, I took the bus up to Lisbon to get any remaining traces of Mickey the Melanoma consigned to the clinical waste bin. The bus pulled out of Lagos station at 05:45. I gazed out through the misted-up window at a monochrome image of Liz, sitting like Little Orphan Annie on the bench seat, chin in her hands and elbows on her knees. It was like a scene out of Brief Encounter, Brighton Rock or The Third Man. All it needed was for her to be tantalisingly revealed and obscured by romantic clouds of steam billowing from a soot - laden 4-4-2 locomotive rather than coughing her way through a choking smog of P3 particulates from an old Tata diesel in desperate need of a service.
Getting thus far through the Systeme National de Saude, the Portuguese health service, had been an experience in its own right. They had come up trumps on promptness, clarity of explanation and clinical competence, an assessment that was enhanced by the supposed maximum wait of 45 days being cut to less than half when a scheduled patient had the decency to catch covid, which left a convenient slot in the schedule, into which I was conveniently slotted. Such serendipity, however, came with its own set of logistical and organisational challenges.
So it was that, just for little ol' me, rules were broken, regulations ignored, and imperious management edicts defied. Out of the blue, on the Monday, I had got a phone call from IPO, telling me to get my arse up to their surgical suite for midday on Thursday, and don't even think about being late.
Oh - and make sure you bring all your drugs with you.
And your hygiene products. Whatever they are. Either way, mine won't take up much room.
Pyjamas?! I haven't owned a pair of pyjamas since I was about twelve, a fact I relayed cheerfully to the woman on the other end of the phone, who had the good manners to giggle coyly. My good humour knew no bounds at this heartening and unexpected development. Had I only known.
I mentioned before, did I not, that the SNS has many things going for it, but it does have a fixation on process, procedures, and protocols. This in itself, is no bad thing. It's a complicated old carry-on arranging, performing, and following up surgical procedures. Such demands do not sit easily with sudden change, especially if, like me, the patient presents with an already complex set of pre-existing conditions made even more bloody complicated by advanced age and a medication regime that makes Keith Richards look like a Jehovah's Witness. Apart from immediate threats to life and limb, which are obviously fast-tracked with a healthy disregard for the rules, everything has its place in the grand scheme of things.
It turns out that, unbeknownst to us, part of this grand scheme of things is that there is a strict order in which things are to be done. Before you get to the actual slicing and dicing, there are a number of rites of passage that have to be completed, recorded, and certificated.
In the correct order.
These include, but are not limited to: a covid test, an anaesthetic assessment and consultation, a preoperative consultation, a multidisciplinary consultation meeting, a lymphoscintigraph and the rapid signing of a blizzard of consent forms and other arse-covering paperwork; all to be completed in the four-day window available before the scheduled surgery date.
Another sine qua non is that these activities will all be carried out at IPO in Lisbon, and will be scheduled by individual departments, seemingly without reference to a central database. I would phone up and explain that I was apparently expected to be in three different places at the same time, all at some ungodly hour of the morning. Harassed secretaries would then engage in a frantic flurry of interconnecting interdepartmental phone calls, each trying to co-ordinate eight conflicting agendas whilst simultaneously holding the entire appointment records file of the hospital in their heads. Eventually, bless 'em, they did it and we ended up with a schedule that was vaguely workable.
The timetable still depended on my turning up before 10 o'clock in the morning.
Kind though it was for them to have thought of me when the vacancy arose, I don't think that they had fully thought through the logistical challenges presented by their more than kind offer.
Now, Portugal is not a big country, even by European countries' standards. It's about 550 km North to South and about 130 km East to West. This means that you rarely have to travel more than about 320 km to get to Lisbon, but you try getting there before midday. You have to leave the day before and overnight in Lisbon. This, though, is a vast improvement on how things used to be. Then you had to leave the week before and travel by donkey and cart.
We went into a frenzy of organisation. Timetables were consulted, buses booked, and arrangements made. We caught the bus on the Tuesday and headed up to Lisbon for the covid test and anaesthetic assessment. Just as we were approaching the outskirts, my phone rang. At the other end was a harassed and most apologetic secretary, ringing to tell me that my surgery had been cancelled.
Some sections of SNS display a somewhat cavalier attitude to case histories and pre-operative drug regimes. In this case, it appeared that someone had broken with tradition and protocol and had actually read the case notes. In them, they found my lovingly hand-typed list of the almost infinite variety of my current medications. Among them was warfarin.
Surgical departments usually blanche and make the sign of the cross when you mention warfarin. It can play havoc with their survival stats. It's an anticoagulant and makes the slightest scratch bleed like a stuck pig. It's difficult to hack and rummage around in someone's innards without making a lot more than a few scratches. If you go under the knife with a system full of warfarin, you'll go very pale (and stiff) before you can say 'exsanguinate'. Well, pale anyway. Stiff would take a couple of hours or so, and even a surgeon would notice there was something amiss before then. The body cavity full of blood would be a bit of a give-away; that and the puzzled-looking anaesthetist tapping his dials and holding his exhaled CO2 feed up to his ear. Standard Operating Procedure is therefore to stop taking the warfarin four or five days before the op.
In view of their belated awareness of my longstanding warfarin habit, they had decided to play safe and cancel. I was way ahead of them. I'd been here before. As soon as they had given me a slot, I'd stopped taking the warfarin, reckoning I could last a day or two without a major stroke before they could start bridging with something like enoxaparin.
"Gotcha!" I replied. "I see your cancellation and raise you three days of subcutaneous enoxaparin." There was a short, muffled conversation and they folded. I cashed in my chips and quit while I was ahead.
So it came to pass that I staggered into the surgical wing (top floor, naturally), bent double under the weight of two rucksacks stuffed to bursting with documents, drugs, assorted previously unencountered personal hygiene products and a pristine trendy set of freshly purchased pyjamas. Primark, since you ask, - €11:50. I was shown into a spacious two-bedded room which sported an ensuite bathroom, two comfy armchairs and my co-occupant - mid-twenties, slim, effervescent, dark hair, big green eyes and a husky voice. Went by the name of Victor.
A nurse came in, threw a couple of packages at us and said "Get your kit off and these on. And don't hang about, we'll be wheeling you down PDQ" Or words to that effect. Victor and I exchanged a few manly grunts and proceeded to exchange our current haute couture for surgical gowns. Those who have ever worn one of these will already be suffering flashbacks. They are cunningly designed to maximise ease of access and removal while simultaneously displaying your bum to everyone in a 50 metre radius and eliminating even the last shred of dignity.
Reputedly, the youth fashion statement of no belt and baggy trousers hanging down revealing underwear or worse, originated in sad imitation of Gangsta culture in US prisons. Belts were frequently prohibited on the grounds that they could be used to cause harm to self or others. Couple this with the lack of appropriately sized clothing and voilá! Now yo' really saggin'.
Saggin? Hah! Yo' some kinda pussy, man? If yo' really wanna look like yo's down from the 'hood, git yo' bad ass into a hospital gown man. Then yo' really gonna spook whitey. Yo' showin' mo' ass dan a ho' at Spring Break.
Act two follows ↆ
Dancing with Doctor D - act two
30 July 2021 | Second movement – Accelerando, Doloroso
Three hours later I was wheeled into theatre. (Calling operating rooms 'theatres' is a peculiarly British practice, which confuses the hell out of foreigners.)
They stuck a line into the venflon and started squirting in the propofol. I always find the actual going under a tad unsettling. No longer having the blind confidence of youth and its concomitant sense of immortality, I'm never completely sure I'm going to come round again. The possibility that this sterile technological tableau vivant of bright lights and beeping machinery could well be the last thing you ever see or hear is a weird sensation.
"Good afternoon, Mr. Newbury."
"Good afternoon, Death."
"Please be so kind as to follow me."
"Do I have any choice?"
It's the sound that comes back first. Low, murmured voices and the hiss of ventilators gradually became clearer and more distinct as the sounds of corridor and ward traffic joined the melée. Then came vision, at first just a white haze, like flying through cloud. This slowly resolved into lights and figures, windows, doors, and furniture. Last to return were self-awareness, movement and finally speech.
I felt like I'd just been on a bender with Oliver Reed. My lips hung open slackly and a skein of dribble trickled out of the corner of my mouth. My tongue lay swollen, loose, and unresponsive. "Boa Tarde" I said thickly to no-one in particular. "Ah! Boa Tarde, Senhor Robert" said a lilting female voice, later identified as belonging to the unlucky nurse who had been charged with ensuring the wellbeing of the drooling foreigner in recovery bed three.
It took her nearly an hour to make me presentable and fit to be trolleyed out of theatre without causing mass panic and waves of revulsion in the corridors. I know I was in a state of advanced befuddlement, but even I could see that we weren't going back the way we came in. It turned out that someone else had disobeyed standing orders and read the case notes. "Because of your heart condition", the nurse informed me, "we have decided not to take you back to your room. You're going to the SO". The Sala de Observações is a sort of halfway house between the ward and Intensive Care. I was taken there and ensconced in bed J, where I found myself sharing the SO with three elderly gentlemen, none of whom looked at all well. It didn't occur to me at the time that there were four of us there fitting those descriptors.
The unexpected change of abode posed a couple of problems. My personal belongings, medications, toiletries, wallet, smartphone, clothes, dentures, glasses and wedding ring were all stashed away in the locker in room 36. I was in no fit condition to traipse halfway across the hospital flashing my bum at all and sundry, but I managed to sweet-talk one of the nurses into getting me at least my phone. When she came back, I rang Liz who was, I'm sure, greatly comforted to receive a call from someone who purported to be her husband and was obviously in the advanced stages of either tetanus or strychnine poisoning.
Most people, or at least most sensible people, are afraid of surgery. This is a perfectly rational response. What is not quite so rational, however, is which aspect of surgery they are most afraid of. Slips of the scalpel do occur, but the one you've really got to watch out for is the gasman. The anaesthetist's job is to poison you to within an inch of your life without quite finishing you off. Almost dead enough for you not to wake up halfway through and sue the arse off him, but not quite so dead that you stay dead and your next of kin sue the arse off him.
They're pokey buggers, anaesthetic agents. They sod about with all sorts of basic physiological processes, and they can hang about in the system for ages. So I laid back and dozed, waiting for my well-toned liver to metabolise the crap out of them. About half past midnight, everything turned to shit. All my usual medications had worn off, but the anaesthetics were still hanging on in there. I went into a cracker of a post-anaesthetic crisis. In the absence of my bisoprolol my heart went into atrial fibrillation and my pulse rate climbed to 200 bpm. Blood pressure soared uncontrollably to 195/150 and alarms started beeping, flashing and wailing, prompting ill-natured grumblings from my fellow internees. The nurses came hotfoot from their station to be confronted with the bridge of the Starship Enterprise after a surprise Klingon attack. Very sensibly, they turned all the alarms off. No-one can think with that racket going on.
I looked at the dials, and then at the pair of perplexed young nurses looking uncertainly at the readouts and muttering darkly about sending me across to ICU and dumping this shitstorm on some other poor, unsuspecting, sucker. The BP measurements climbed inexorably upwards to 200/160. BPs at this level cause the blood vessels to leak like a garden hose after a wrestling match with a porcupine and the subsequent collapse and shut down of systems throughout the body. I felt a tap on my shoulder:
"Good evening, Mr Newbury."
"You again, Death. You don't give up easily, do you?"
"Comes with the job. Sorry."
My thoughts turned to Liz and a wave of hollow emptiness and unbearable loss flooded through me as I contemplated the awful possibility that the view from the bus window stood a good chance of having been the last time that I ever saw her. I contemplated phoning her, but dissuaded myself on two grounds; it would do her mental equanimity no good to be woken at two in the morning by a hysterical phone call from a pathetic blubbering husband feebly blathering on about how much he loved her. On top of that, if I didn't die I'd look a right tit the next morning.
The on-call medic arrived. She didn't look much older than the nurses - a hell of a lot of responsibility on young shoulders. She squatted down beside me. "We've got to get your blood pressure down." she said. "No shit, Sherlock" I replied. She looked understandably confused by the idiom.
She tried captopril to no effect and nitro-glycerine, which fared no better. Then a thought struck me. My meds had been locked away in room 36 for hours. I've had atrial fibrillation for decades. I can recognise the symptoms and the ECG trace of a severe attack, and this one was a cracker. "Try bisoprolol, 5mg," I suggested.
She thought about it for all of five nanoseconds before dispatching one of the nurses to pharmacy. I chewed it to speed up absorption. I was expecting it to take two hours to take effect. It started to kick in after less than half an hour. By three in the morning everything was stable. Bp 125/67, pulse 75.
Act three follows ↆ