Archive for March, 2016

In the Big House

I was on orthopaedic ward. Even though I was sick and in pain, the self-appointed ward social director Jim introduced himself and the members of the Order of Godot. All I wanted was to stare at the ceiling, but that wasn’t happening. Jim thought he spotted a kindred spirit in me as soon as I arrived. I was a Sun-reading, white van driving, sowf Londoner salt of the earth of Irish extraction. He was so pleased to see me and talked so much and I was so groggy I was unable immediately to dispel any of his erroneous assumptions. In the next bed from me was Stewart who was awaiting return to a nursing home after an unsuccessful attempt to decompress nerves in his collapsing neck vertebrae. He lay or sat in a neck brace the entire time quietly enduring his pain and rigidity like an old Labrador with a bucket over his head to prevent him from chewing his stitches. He listened impassively but alertly to his radio with an earpiece and was fond of his jigsaw puzzles. Interacting with him was not easy, but it was difficult to know where the deafness began and gentle dementia ended.

Across from me was John. Don’t worry about him, he’s away with the fairies, he is. John was doubled over with a deep forbidding scowl on his face. Occasionally his eyes would dart around the environment with suspicion. Occasionally he would call out indecipherably, sometimes seemingly angrily at some unknowable wrong. Most of all he dozed in a half-there torpor, falling intermittently fully asleep. The nurses approached him apprehensively as he hated the uniform and had a history of lashing out. He was uninterested in eating and doubly incontinent. His bedding rested inches from the floor due to the risk of his falling from the bed and injuring himself, which was, I suspect how he had entered the hospital for a suspected fracture and was now unable to be discharged for there was no place for him to go.

He was howling all last night, weren’t you John? Jim good naturedly chortled. He’s been in here longer than me and I’ve been here nearly 2 months.

The other bed empty and awaiting the arrival of Vincent who had broken his hip and living alone had had to drag himself to the next room to call an ambulance. However, other than a desire to finish the bottle of red at dinner and open another, he was fairly fit for his 70 odd years.

Jim had had a stroke 10 years previously that had rendered his left arm and leg useless. He had broken his hip in a fall and as with the majority of my ward-mates, with nowhere to go he resided in the orthopaedic ward. A constant stream of Gawd-bless-you’s and My-darlings toward the nursing staff thinly veiled an unquenchable desire for attention and nurturing. His dementia took a while to reveal itself in that I just thought he was pain in the arse. But it was the collection of behaviours that revealed that while he lorded it over his ward mates for their loss of marbles, he himself had not been unscathed by the ravages of time. It could be seen in the exaggeration of his personality; the hoarding and decanting of urine bottles; the repetitive and obsessive self-cleaning, particularly of his groin; his para-sexual pleasure of the process soiling the bed and being cleaned by nurses. His memory was functional, however as a skilful turner of a yarn, he conflated and adjusted his recall from history into a narrative of his own redoubtable resistance to adversity and unfairness. In this way while dominating the discretionary time of nurses, pouncing on them as they entered the wing to do just one more thing (some paper towels, another urine bottle, when is that nice young doctor coming?), he maintained out of what he imagined was the hearing of the nurses that he was always ignored and had not once had a nurse say a nice thing to him.

I flatter myself as a vital, physical and fit man. I attend the gym, run half-marathons and climb mountains. Admittedly, I have succumbed to middle-age spread and I am now verging toward the white-haired. Nothing prepares you for the shock of close confinement with your medical peers, as if Dobbin had just realised it was the knackers yard. Up until this point I had felt I was a youngish man with a grievous injury. Now I felt the harsh reflection of a crushed and bedraggled man of advancing years with an injury that promised nothing other than increasing infirmity and disability and only the sweet release of finally losing my self-awareness as senility stole the years of assiduously acquired education. They say that there is a down period after general anaesthetic. Oh, fuck. No point in panicking. I couldn’t get out bed let alone run in circles screaming and ranting, demanding to know where all the years went.

It was lights out time anyway. In the wing across the nurse’s station from us a woman called out repeatedly for god-knows-what and could not be consoled.

Gawd, listen to her go! said Jim.

A nurse came to flush the cannula and deliver the amoxiclav and the metronidazole drip. Flushing the cannula is increasingly painful the longer it sits in the vein. My veins seem not to take the stress well and after 48 hours I have haematomas surrounding them and the flush is sharply painful and the IV barely makes it through. I thanked the nurse when she had finished and I made it a policy to be from then on unfailingly polite to the nurses as they did their job. I figured it must be a difficult enough job without me complicating things any further.

Metronidazole has quite a few side effects and it made me nauseated and sweaty. My skin crawled with urticaria and I found my own smell strange and unpleasant. No-one else could smell it. One nurse noted helpfully that she’d heard that that was a symptom of pregnancy. We agreed it was unlikely, given my age.

 

Amoxiclav is a variant of Amoxicillin a type of the original antibiotic penicillin. Amoxiclav has clavonic acid added. Penicillin resistant bacteria use an external skin to prevent contact with the antibiotic. Clavonic acid disrupts this resistance and makes penicillin useful again, until bacteria develop a method of avoiding even this refinement so that the arms race may continue.

 

I spent the first night in orthopaedics, dozing on oromorph, my bandage trussed left arm resting on its own pillow. The fixating rods were fanning out from my elbow like the crest on a dinosaur. I tried to freak out as quietly and as slowly as I could. My shoulder ached at the position, but as I struggled to find a comfortable position the sling stretched and loosened. I’d asked if I could take it off and I was advised that it would be best not to by nursing staff. Half way through the night I couldn’t tolerate it any longer and slipped the neck loop off. I expected against common sense, some sort of medical calamity as the loop fell on my chest and my shoulder finally decompressed. I was naughtily ignoring advice after all. But no disaster, just my shoulder sinking into grateful relaxation. It’s always easier to advise against any change, based on a fear of being held to account for taking a decision.

I watched the morning slowly arrive. 4am to breakfast is the nicest time in the ward. After the last vital statistics has been taken there’s a period of peace when the agitated patient may find a little peace in sleepy oblivion. The nurses are tired, finishing the night’s notes and preparing for the morning drug rounds. While I lay still, the general anaesthetic hangover and the malaise that seemed to accompany the IV antibiotics prevented all but brief snoozes. I was still in a theatre smock. The theatre smock is short sleeved and laced at the back. Because the fixation rods would have prevented easy removal the garment was laced under my left armpit so that I wore it cave-man style. I sweated constantly and the sheet stuck to my back and bunched up beneath me.

Hospital mattresses are necessarily waterproof, so after a while I stewed in my own juices. I shifted and wriggled to find more comfortable positions, my left arm anchoring me to its pillow. The outlandish external fixations protruding outwards made me always mindful not to move too freely. It is unnerving seeing something attached directly to your core stick out of you, like observing your intestine protrude from your abdomen. The truth is that all but the most violent knocks to it were relatively painless. But even simple sensation to your bones has a way of producing a protective flinch.

The day after surgery, I had surprisingly infrequent pain. It was merely distressingly uncomfortable. When the pain came it was serious and angry. And of course movement was formidably scary with the metal work. I was intimidated into not moving like a rodent under gaze of a serpent. Being immobile, hungover and exhausted, I was the least resource intensive nursing patient in the room. This was despite being the most acute and the least routine.

I sat or reclined in bed and watched the daily nursing schedule roll out. Morning drug dispensary, change of shift, breakfast, lunch orders, vital statistics, IV, notes, toileting and bathing, arrival of the Registrars and medical students, change of linen, vital statistics, medical inspections and consultations, IV, lunch and drug dispensary, dinner orders, physiotherapy and occupational therapy rounds, vital statistics, official start of visiting hours, one-off medical consultations, arrivals from afternoon surgery recovery, drug dispensary, dinner, breakfast orders, IV, official end of visiting hours, vital statistics, notes, change of shift, final drug dispensary, lights out, final IV, vital statistics, notes, and lastly wee hours vital statistics.

The schedule, jam-packed as it was, tyrannised the nursing staff. Regular incidents such as bed soilings or patient requests, and nursing resource intensive patients who were unable to communicate or feed themselves crushed the timetable of a nursing staff already under the hammer. Given the pressure it was surprising that they responded the positive way they did to my sudden and irregular requests for oral morphine.

Jim asked a passing nurse for some paper napkins.

I asked if I could sit in a chair. The junior nurse knew that a decision like that was well beyond her pay grade, she was doubtful if I could make it either. So lay propped up in my damp and sweaty bed linen. Jacquie asked if there was anything I wanted by text. Underpants, track pants, a t-shirt with the sleeve cut open. Did I mention underpants?

My phone worked sporadically as there wasn’t good data coverage in the ward and there was no wifi. Still the phone was a prized connection with the outside world. Marooned on bed surrounded by Hogarthian caricatures the phone became a life-line. It was a way of determining whether I was thinking straight. It reminded me that there was only a little time a few days to go before I could be discharged. After that a few days before I returned to have the arm fixed, and then I could rehabilitate my arm myself. The future took on fresh limpid colours of a sunny upland of constant incremental improvement. The future had no relation at all to smells of incontinence and disinfectant.

Jacquie arrived after lunch with clothes. She was optimistic and more relaxed than before. She didn’t seem to notice my despair, which while not the first topic of conversation, I wasn’t burying in smiles. She rationalised away me noting the average age of the ward and my place within it. She wasn’t having it, and I realised the self-indulgence of wallowing in it. She helped me dress on the side of the bed. She undid the surgical smock and we left it at the end of the bed. The nursing staff noticed the procedure.

Getting upright? Said a senior nurse positively, Very good. Would you like to sit in the chair for a bit?

I would like to walk later, I said hopefully.

We’ll see, said the nurse.

Jacquie had brought my phone charger, some fruit and a copy of the economist.

I figured you’d come out of the anaesthetic hangover and be instantly bored, she said. But also I know you’ve got the attention span of a goldfish.

Is this your daughter? Asked Jim. As if I hadn’t gotten over the admitting Doctor’s mistake. Your missus? Oh very nice.

I suddenly resented him even more. Take your filthy mind off the woman who inexplicably loves a man apparently 20 years older than her.

Thanks Jim, I said.

Jim eventually went back to obsessively scrubbing at his groin with the paper hand towels he hoarded.

Let’s have a look at the bandages, said Jacquie. She had always had taste for the medically macabre and gore. It was particularly useful in situations such as these. I couldn’t help thinking on a number of occasions that she had missed her calling as a surgeon. The metal fixators were gently oozing and only a little blood caked on the gauze. Jacquie was satisfied and we talked for a bit. Her work had been super supportive of her taking time off to see me. She figured she would go into work the following day. A friend had offered to drive us from the hospital to our home when I was discharged and Jacquie thought if it happened in the evening she would be able to work that day. Jacquie is always conscious of her responsibilities. She was trying to catch up on sleep. I apologised for my actions putting her through this. She didn’t care so long as I got the use of my arm back.

After a time, I started to doze and she left. Between IVs and vital stats time on ward drags. The memories I have of this time elide into each other. It’s just a bowl of soup with lumps of discomfort, illness, and pain in a sickly stock of boredom.

The next day a registrar came to see me for a post-operative inspection and redressing of the external fixation. She was British-Persian I believe and devout enough to cover her hair. She was straight forward although not overly confident. She asked me what I did for a living and I told her I was an osteopath. Like every doctor before her up until this point she grimaced.

Don’t do that! I said. The outcome statistics for this type of fracture aren’t that bad.

I’m sorry, I didn’t mean that. I just know how long it’s going to take for you to get better and I know you only make money when you work. That’s all. Of course the outcome will be good for a man so relatively young, she recovered quickly.

She explained the procedure and the fact that they were now looking for signs of osteomyelitis. All things being well, as they almost certainly would be, I was scheduled for an ORIF with or without a radial head replacement after 5 days.

 

ORIF- Open reduction internal fixation. Large or complicated fractures with need to be fixated so that the bones can be aligned and the callus formation isn’t disrupted by the fractures moving against each other. 

Osteomyelitis is an infection in the bone. It can be very difficult to detect if there isn’t an obvious fever or if there is a comminuted (complex jumble) fracture. Infection can lead in 2 different disastrous directions. It can spread and lead to cellulitis and septicaemia and that eventuality can be fast developing and life threatening. It can also be chronic, small scale and localised, but prevent bone union and lead to the need to excise the infected bones. If there is a prosthesis nearby, it can lead to the failure of the prosthesis.

 

She opened up the dressing around the external fixation and declared herself content that there was no sign of infection. She did a pretty good job of wrapping me back up again. At the end of it she told me that they were sending me for a CT that day in preparation for the second operation and reassured me that everything was going well. I thanked her and complimented her on her wound binding skills. She impressed me with her professionalism and her human manner. That was the last time I saw her.

A few hours later I was picked up by an orderly pushing a wheelchair to be taken to radiology to have my CT scan. On arrival I waited only a few minutes to go it.

Can you lift your arm above your head? The radiologist asked.

I tried and found that the upper rod fixator that went into my humerus when through the belly of the tricep. If I tried to lift my arm above my head it would pull against the muscle and start to tear at my flesh.

I can’t actually do it, I told the woman. See, I demonstrated. I could do it but it would mean making a tear in arm and bleeding on your equipment. I’m willing to do it if it means getting the operation, I said a little pathetically.

The woman’s eyes for a moment glassed over. We tried various positions, but seated or lying, any time I tried to raise the arm up, the rod pulled implacably on the muscle.

Well, if you can’t do it you can’t do it, she said and I was wheeled back to the ward. That was the last time it was mentioned. If the CT was important no-one seemed to miss it, until that is after the second operation when I explained to the surgeon why it hadn’t been done. A CT isn’t a trivial investigation. The equipment is a capital asset and the training of the radiologist isn’t negligible. It requires exposure to ionising radiation a hundred times stronger or more than a standard x-ray.

Back on ward, little had changed. Godot had not arrived. Jim’s groin remained to him unsatisfactorily swabbed and he attacked with a meticulous vigour. Around him was arrayed his empire of pressed cardboard urination bottles. He measured out and decanted his emissions from one receptacle to the next. It was a ritual of organisation, a cargo cult of one of self-possession and economic activity to displace the meaninglessness of existence marooned in an orthopaedic ward on the NHS.

In the periphery of my visual field I could discern the flittering movement of a familiar black figure. I bit hard and refused to turn my face to look. I was not going to succumb. The worst outcomes are never the most likely. I was not, nor would I become a fellow of the college of bed-blockers. The social faux-pas of a 30-something doctor could not define me as aged, despite my haggardness. If no clinician was going to lead me through this process, I would rely on my own counsel.

Morals of the Story

The NHS has a long history of finding a way of delivering on limited budgets. Taken over all, the NHS is phenomenal value for money. While the average health spend in western Europe is over 11% of GDP, the NHS hovers just over eight percent. While that is a relative measure, if one looks at the health spending per person in absolute terms, in 2014 my home country New Zealand spends more than the UK despite having 10% less GDP per capita. [http://www.oecd.org/els/health-systems/oecd-health-statistics-2015-country-notes.htm]. My point being is that the health outcomes from the relative spend are superb.

One of the major issues for the NHS is bed blocking. This is when a patient enters hospital for treatment and the hospital is unable to discharge due to there not being anywhere appropriate to the needs of the patient for the patient to go. This is not a medical issue so much as a result of a number of social and economic forces straining the creaky infrastructure of care has accreted under UK Governments over the last quarter of the Twentieth Century and into the Twenty-first.

The trends to live longer, to live alone and distant from family, to have a managed chronic disease, to live long enough to be afflicted with dementia, even the inflated costs accommodation collide to recruit an ever-burgeoning army of the elderly with a kaleidoscopic spectrum of expensive on-going and escalating social care and primary health care needs. In the US (where heroic medical interventions on obviously dying nonagenarians are routine) it is estimated that half of all life-time spending on healthcare occurs in the last year of life. The increasing intensity of health and social care resource use in old age is a fiscal burden that can’t be escaped.

In the UK, politicians have struggled hard to control health cost inflation and to a certain extent have succeeded splendidly. Social care costs are much harder to control and resource management decisions many times more electorally toxic. Any change in funding or resource equations are poised for a government between the Scylla and Charybdis of fiscal blow out and the televised horror of grandma freezing a pool of her own urine. So the NHS takes the strain in terms of bed blockers and every day ward sisters play a game of musical chairs for beds in care homes or sheltered accommodation or social worker approval for return home for their residents. And residents every day become slightly more dependent and institutionalised.

But, gentle reader, don’t think for a minute that if the Treasury opened the vaults and allowed legal tender to flow unfettered into social care that there would be proportionate savings in the NHS. I worked for a time in the New Zealand Department for Corrections

 

Who is my doctor?

One of the great surprises of the process is how as a patient of the NHS you have no direct relationship with the doctors monitoring your case. Neither do you have a relationship with the junior doctors assigned to do the more menial tasks of care. At the lowest end the nursing staff are almost constantly taking pulse, blood pressure and temperature, much of the time to no discernible purpose. The pointlessness of this routine is only highlighted when one is woken at 4am from a necessary and healing sleep to provide data points on a chart no-one will ever read.

I didn’t demand to see my doctor, but I was surprised when the nursing staff started talking about discharge when I had never seen my surgeon from the first operation after surgery nor the consultant supervising future treatment. I only had seen my first surgeon (who will make a reappearance later in this narrative) because I had asked for reassurance. That had been a moment akin to Oliver asking for more gruel. So I wasn’t eager to see him again.

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Into the Belly of the Beast

I arrived at Heathrow at about 9.30pm. I didn’t ask for help on the plane for my slung left arm and I didn’t receive any. By the time I got to baggage claim I was unreasonably in a filthy mood for the indifference to my pain and disability of everyone I encountered. By the time I made it to Jacquie and our friend who was driving us to A&E I was ready to burn the airport down.

Jacquie was understandably anxious and despite the cast the pain was slowly building. We drove from Heathrow and arrived at our local hospital at 11pm on Sunday night. We thanked our friend and walked into the emergency department. It was sparsely populated by three clutches of people on the rows of plywood and metal seats. The dim florescent lighting cast a troglodyte shadow across these supplicants to the NHS. I approached reception behind thick glass and gave my details loudly to overcome the sound insulating effect of the barrier. A barely perceptible hum deadened the acoustics of the cavernous waiting room. I did as I was told and sat down to wait my turn.

After five minutes, not very long, I was summoned to the triage nurse to describe my condition. I gave a precise anatomical description of my fracture, when it happened, the radiological findings. Having given a dispassionate and clinical report I wanted to end with something that described my feelings and my state of being to allow the practitioner to judge how I was feeling and give her an opportunity to reassure me.

There’s two last things I want you to know, I said loudly through the gap in the seemingly bullet-proof glass, First, I’m struggling because I’m in a lot of pain. Second, I’m really worried because I work with my hands and I’m worried by a loss of function.

You can’t expect to come to the NHS at 11pm on a Sunday night and get an operation, she said.

I was taken aback. I’m not looking for a fight, I said.

I’m not looking for a fight either! she responded.

Within me I strangled a tongue of rage. I needed her help. I had no choice. I had to suck it up.

I offered the orthopaedic report and the CD with the 24 hour old x-ray.

We can’t use those in the NHS she said. I smelt the vague waft of contempt toward my offerings and I felt deep offence at the slight to those wonderful clinicians who had helped me in Spain. She told me to go sit down and she would call me.

After 10 minutes she called me through to a room with even worse lighting than the stygian waiting area. There waiting for me in a paper cup were 2 ibuprofen and a paracetamol. In the same way as one may be insulted with faint praise, a patient can gauge the seriousness with which a practitioner takes them. Her response to my presentation was by the book. She had responded to the letter to what I had said, but had entirely overlooked or ignored the substance. I felt the presumption that I was a princess, possibly even “drug-seeking”. I was very angry. But the powerless may not express anger directly. My only option was submission and an attitude of what used to be known in the military as dumb insolence. I took my medicine and stared at the floor.

She told me to wait in waiting compound. Ten minutes later she came out and told me that they were waiting for me in radiology. We were to follow the yellow line on the floor that lead away from holding tank and into the labyrinth. The yellow line twisted and turned, faded out through areas of vinyl where it had been buffed out of existence and re-emerged. We came to an area that had too many seats for the small area, an old man propped up in a gurney and couple of anxious middle aged parents of a child elsewhere. A sign on one door said x-ray room. This must be it.

A doctor arrived and the middle aged parents followed her away. An orderly came and wheeled the elderly man back to his ward. Jacquie and I sat alone. I felt her anxiety for me and I felt guilty for putting her through this and this threw fuel into the furnace of the anger I felt. It was after 1am. After 45 minutes the triage nurse appeared. She had come to find out where we had gone.

I thought you might have walked out, she said. I stared at the floor.

The radiologist is on his break I think, Jacquie informed the triage nurse from a snatch of overheard conversation half an hour previously. I stared at the floor.

Oh, I’ll find out what’s going on, said the triage nurse and we were alone again. Not long after a female radiologist appeared and took me into the x-ray room.

Can you put your arm on the table? Hold still <pause click bing>. Oh. You’ve broken your elbow not your forearm. I’ll need to retake the x-ray. Why did she want an x-ray of your forearm?

Because she wasn’t educated enough to know what I was talking about when I told her I had a comminuted fracture of radial head and ulnar just distal to the olecranon, I thought. I had assumed that a triage nurse had good enough anatomy to use a dispassionate clinical description. I realise now that not only had she not understood she probably thought I was being high-faluting and presumptuous.

We weaved back through the labyrinth following the yellow print road to the waiting pens. The triage nurse beckoned us through to the treatment area. She tried to strike up a conversation with us which I deputised to Jacquie having found the floor in especially dire need of a good hard stare. It was getting toward 3am at which time she was handing over to the new shift triage nurse. The x-ray arrived by email and the old triage nurse opened the image on the wide screen of her computer.

Wow, she said. It’s the elbow.

It’s not my arsehole, I thought. And where do you get off exclaiming in front of a patient? I kept dumb.

The new triage nurse arrived and cheerily introduced herself. She went over to the computer and the departing triage nurse and viewed the x-ray.

Oh gawd, said the new triage nurse. We’ll need to call the orthopod consultant.

The departing triage nurse said goodbye and Jacquie thanked her for her help. I may have nodded, I may have said goodbye. I didn’t smile.

Twenty-five minutes later the consultant arrived. The triage nurse opened the x-ray for the consultant to view.

Holy shit, he said.

I snapped. This is amateur hour. I’m the patient. I am anxious. Part of my care is the knowledge that my carers are unfazed by my condition: that they know how to help me. Having heard someone exclaim for the third time having looked at my x-ray, I’d had enough.

I can hear you, I reminded them.

The new triage nurse thought I was being humorous. The consultant turned to look at me for the first time.

We’ll need to have a look under the cast, he said.

The new triage nurse came over with a pair of scissors and started to cut the soft underside of the cast away.

I’ve got an open wound adjacent to the fracture. I’m afraid I’m going to bleed everywhere.

Don’t worry, he said, we do this every day.

When the nurse pulled away the gauze blood dropped thick and congealing over my trousers and the floor. The splatter made both of them jump back in a mockery of his earlier reassurance. Jacquie offered to hold some bandage against the bleeding wound. The new triage nurse took the hint and bound the wound.

Okay we’ll need to send you to get a canulla and some pain management said the consultant authoritatively. The new triage nurse escorted us away.

At the canulla station I told the nurse apologetically that I had elusive and deep veins. She told me she was very good at this and tap-tapped at the back of my hand. She inserted the needle speculatively and probed deep and backed off, then left, then right, further right and found a vein. It was over in a couple of seconds and my passive face hid the sting.

There, she got it first time, Jacquie said in mild admonishment of my lack of faith in the nurse’s skills.

Yes, the nurse was very good. I said.

All in a day’s work, the nurse said.

I was wheeled into the main part of accident and emergency for my first examination and some pain management. They gave me tramadol and gentamycin (a heavy duty antibiotic). The consultant talked to Jacquie as I was admitted. There was something about his smile as he talked to her. Jacquie had the agenda to make sure I got treatment that night. Her nightmare had been that some functionary would have heard broken arm, seen the cast and assumed that treatment wasn’t urgent and sent me home to present the following day, maybe without appropriate painkillers. So for her it was a moment of triumph that I had not been told to come back tomorrow. She was visibly relieved.

She came over and we talked. I told her now that I was in the system she should go home and get some sleep. I would update her by text if I needed her. She left and I was alone on the gurney in the Emergency Room.

The consultant came over to explain what was happening.

As I explained to your daughter…

WIFE, I interrupted.

Yes, your wife…He went on to emphasise how bad the fracture was and how, due to the open wound next to the fracture and the length of time since the accident, they would prioritise the prevention of infection and most probably do an external fixation for 5 days followed by an internal fixation (ORIF) which is a metal plate to which they attach the fractured bone using nails and most likely a radial head excision and replacement with a prosthesis. I was being lined up for surgery that morning. What job did I do?

I’m an osteopath. He sucked his teeth and made a pained face. I was starting to get unnerved.

I don’t mind a radial head excision I just need the best functionality I can get. I then repeated myself with slightly different wording just in case he didn’t understand me the first time: Best. Functionality. Possible. He got out a permanent marker and put what looked like a hobo mark on my shoulder. It was a crossed circle with an arrow down my arm and some hieroglyphs. I presumed it meant that while I was irascible my elbow was good for a hot meal and my daughter was cute.

I thought that I must look pretty ropey if a doctor thought I was old enough to be my wife’s father. Yes I have grey hair and she doesn’t, Yes my grey stubble tends to make me look like a homeless alcoholic as it lengthens into a beard. Jacquie, who is officially a year older than me, could plausibly be 10 years younger than me on my bad day and her good. But could she really be 20 years younger? I was climbing a bloody mountain 48 hours previously! I assiduously avoided my reflection in my travels in a bed to a ward. I had enough to worry about.

In the ward I tried to rest, but I couldn’t sleep. It was morning now and light. I tried my best to be in a state of mindfulness, but failed miserably. Sooner than I thought an orderly came to take me to theatre. I was wheeled straight into operation preparation. A nice English Anaesthetist introduced himself and said that there was no need to hang around, in with the second canulla and count backwards from 100.

I need reassurance.

Oh, what do you mean reassurance?

While I seem calm, I haven’t slept in a day and internally I am a mess of apprehension. I’m worried about the outcome. I’m an osteopath and I need my arm to work. I need someone to reassure me.

Oh I see. Well I can’t do that properly. I’ll go get the surgeon.

After a few moments the forbidding figure  emerged from the OR with a faint but distinct air of annoyance. It was my first encounter with Mr M. At other times he could be a man of refined sensibilities and exquisite courtesy. Today he was not.

I explained how in the delay and the rush, no-one had definitively told me which surgery would be done today. I was worried and I needed to reassured that the surgery would lead to my recovery and I would be able to return to my profession, eventually.

Well, he said, there’s no way we’ll be able to fix it today. It’s very bad. It will need another surgery, maybe more than one. The damage is too extensive and the risk of infection is very high. Today all we can do is externally fixate. As to functionality I can’t make any promises at all. In fact,…

He paused to draw breath, I don’t know what other body blows to my hopes he was about to land, because I closed down the conversation with thanks and assurances that I didn’t need to hear any more. Mr M was old enough to know when a nudge was as good as a wink and departed through the OR doors.

The Anaesthetist emerged into my line of sight from above with the gas mask for me.

I guess that’s not what you wanted to hear, he said.

I tossed my eye brows up and now under starter’s instructions inhaled deeply and slowly.

I emerged from my stupor being wheeled into a room on the ward. Jacquie arrived there soon after and while my memory was patchy, I remember being surprised I didn’t wake up in recovery. I was in variable but sometimes extreme amounts of pain. But reassuringly Jacquie was there. The ward nurse came in to see me. He asked how the pain was which at that moment I found perceptive on his part, but God knows what I had said up to that point. I didn’t think I had been howling. He offered oral morphine if he could find someone to sign it off. You see, he explained, I was in a general ward, not orthopaedics as the orthopaedic ward still hadn’t a room available. He didn’t have the training to allow release of pain medication.

Another nurse, a cheerful guy, came in to take my blood oxygen saturation, pulse and blood pressure. He was easy to talk to and cheerful. He noted I had the same steady lowish blood pressure as always, noted I was in pain and said he would ask the staff nurse. He departed after taking the tests.

My arm was trussed to me with a tight sling made of neoprene sponge around my neck. External fixator rods emerged from the wading around the back of my elbow at acute angles held together by a Hofman fixator looking for all the world like a mechano set had made love to laboratory equipment and these bastard children had laid aggressive claim to my arm. The pressure on my neck and shoulder from the stressful position I was trussed into were causing pain, but I assumed wrongly it was pain referred from my elbow.

Agonies would come and go and I became aware that I was unable to deal with the pain as I was quite mentally altered from the effect of the anaesthetic and I assumed the morphine. After what seemed an afternoon, but Jacquie subsequently tells me was 30 minutes the staff nurse returned to say he had paged the nurse pain specialist to find out if I could have more morphine.

The pain was becoming very difficult to manage and I felt I had to appear brave for Jacquie, but obviously I was doing a poor job. The cheerful chappie nurse came to take my statistics again and suddenly the morbid surrealism of taking my blood pressure seemingly every 5 minutes but not addressing my pain overwhelmed me.

Oh what’s the point? I responded to his well-intentioned rhetorical question, shall we see what your blood pressure is?

Jacquie admonished me immediately and I apologised abjectly, and the nurse didn’t skip a beat or break a smile. He completed his task and left and I made my excuses to Jacquie. The pain subsided as I squirmed the sling into a new less tortuous position on my neck and shoulder.

The Staff nurse arrived triumphant with a disposable kidney pan with oromorph in it. I was allowed 7.5 dose. When he walked into the room, I felt no pain, and high as I was I blurted out that I didn’t need it.

You’re taking it, said Jacquie with menace. And suddenly the wisdom of Jacquie’s philosophy was immediately and blindingly obvious. I didn’t notice at the time but there followed the oromorph ritual whose climax like a bird feeding a chick was a squirt of clear sweet raspberry flavoured syrup into the mouth with a needleless syringe. All going well it all ends up in the mouth and none on the chin.

Dinner arrived. I didn’t want to eat, but I knew I should. Jacquie insisted and fed me. I think it was chicken pie. For institutional food it didn’t look bad, but I just didn’t want it. Jacquie had to cut up my food for me, so that even before it passed my lips I resented it for reminding me that my left arm was out of action. Jacquie suffers from a strong gag reflex so was unwilling to place the food all the way into my mouth. After the third attempt to get the plane into the hangar, it was apparent that she was getting the food close to my face and jab-flicking in the general direction of my mouth. After a quick bicker, we tried the strategy of she giving me the loaded fork. I chewed the food with saliva-less lack of enjoyment. It was lumpy wallpaper paste as far as I could tell. Whatever flavour I could discern disgusted me. The sensation of food in my stomach was not a nice one. Jacquie encouraged and reasoned with me. When cajoling didn’t work she tried guilt, when that no longer worked, the meal was finished.

I got more in you than I thought was going to get, she said

As the Bishop said to the Actress, I replied and gave an unsatisfying burp.

Can I take the sling off around my neck? I asked the Staff nurse on a visit to see how I was. You see it’s very uncomfortable and it’s causing most of the shoulder pain.

I don’t know, said the Staff nurse regretfully. You’ll have to wait to ask someone on the orthopaedics ward.

I don’t remember there being any change after the oromorph. I didn’t get any higher. The pain kept dancing its intermittent carrousel with me. I did feel the relief that something had been done, and in a moment of clarity I realised that removing the sling could not have any effect on the elbow or the fixator rods. Moments later I was distracted away with the fatigue and pain. Later, I talked to Jacquie about it, but we both agreed that we couldn’t risk any change before we talked to someone who would know.

The staff nurse arrived with the orderly to take me to orthopaedics after four or so hours, my space awaited. The nurse was anxious and relieved that I was going to somewhere he knew I would get better more informed treatment. I thanked him. His essential niceness and dedication to his profession was obvious. But his lack of authority and inability to deal with my problems were also apparent.

I was wheeled into a five bed ward. The first thing that was apparent was that despite my 45 years, I was the youngest by a good 25. I had arrived. It was clean but a little cramped. From experience I knew the sooner I got up and walking the sooner I would be discharged. But those thoughts were precocious. What I wanted to know was how was I? What had been learned about my condition in the OR? What was the strategy from here?

Having said that I was still out of my head with pain and morphine. It was after 8 pm, now that I had arrived the oromorph was flowing regularly, but never in the same amount. It wasn’t as if a nurse would discuss my pain with me a tailor the dose to my perception of pain. Neither was there any apparent overarching strategy of tailing off the dose. The oromorph was presented, sometimes at some time after I had told a nurse my pain was worse, sometimes unexpectedly at random at unpredictable doses of which the mean was 5, and at multiples of 2.5. It was offered at a dose which I either accepted or declined.

Asking about dose lead to a whiff of suspicion. In fact, asking about medication was also viewed as unusual. Drug rounds were every four hours. Being dopey on morphine, I looked at every pill and wanted to know what each looked like and the dose. I didn’t challenge a single pill, but felt the nurses anticipating my non-compliance or worse preparing my case for a complaint.

I was on intravenous amoxiclav and metronidazole antibiotics every six hours. I was on paracetamol and ibuprofen for pain and oromorph on demand.

Every four hours my vital statistics were taken, night or day, asleep and awake. The statistics never materially changed, and they never showed anything of interest. But the schedule meant I could never look forward to more than four hours’ continuous sleep.

Morals of the story

In the NHS don’t expect your triage nurse, doctor or surgeon to show concern for what you are going through in your health problem. And don’t expect a show of vulnerability to get you “special treatment” such as empathy. This sounds more cynical than it is, NHS staff are very professional and care deeply about their job. But there are incentives and pressures that subtly but profoundly affect their relationship with the patient. With the history and economics of the NHS, the culture is so deep that pointing out this fact will be met with confusion followed by angry denial and then special pleading.

As a social and economic transaction, medical treatment is infused with cognitive conflicts for both the practitioner, but especially the patient. The patient seeks to acquire what the practitioner provides not out of want, but necessity. Typically, it is a return to health and/or the cessation of pain. The practitioner is imbued with for all intents and purposes a permanent information superiority. In normal economics, the value of the transaction can be set by the market where Adam Smith’s invisible hand can accumulate all information. In healthcare with its permanent information asymmetry, value seemingly may only ever be set by proxies for inputs. The value of the doctor’s time is usually determined by his schooling, qualifications and seniority within the profession.

Culturally, the patient approaches the doctor as a supplicant not as a trading partner. As a patient your desire is for the oracle-priest to peel away the uncertainties and dreadful omens, in other words to diagnose. And then for this powerful individual to draw the pain and sickness from you by a series of trials and rituals, again to translate, procedures and tests. The greater the fear the patient holds, and the more senior and illustrious the doctor, the more the relationship is a social rather than economic in flavour.

But this isn’t a simple matter of doctor dominance. The patient wants what the patient wants, and if the doctor doesn’t deliver or come close there will be a reckoning. Particularly if the doctor does not engage or demonstrate to the patient an acknowledgement of their humanity and suffering. In the US nothing determines whether a patient sues for medical mal-practice so much as how much the patient likes the doctor. This takes precedence over actual competence or otherwise of the practitioner. If the patient feels that the doctor did their best by them, they are much more likely to disregard evidence of incompetence in their treatment. So much so that clinicians are now advised in training in the best ways to engage and acknowledge the patient. You’ll sometimes hear it in the tortured robotic language of recent medical graduates. It is a species of political correctness that certain less socially skilful practitioners use to tick their mental check-list of patient engagement.

But nowhere, especially not in the United States, is there a utopian direct economic relationship between doctor and patient. Across the world in different national health systems, there are a myriad of interlocutors, middlemen, transaction consolidators, buyer groups, seller groups, insurers and administrators that interpose themselves economically between patient and doctor. But in the NHS, there is a stark economic gulf between patient and practitioner. There is the illusion, created by the national monument that it “free at the point of care”, worshiped almost universally, a protective shibboleth repeated when discussing health policy by politicians both left and right, that freed from the economic transaction, doctors may work solely in the interest of the patient.

I’m not criticising it. I don’t want to change it. I just want to shed light on how it affects the relationship between the doctor and the patient. You may think that I am over stating it that the principle is worshipped, but the depth of belief in this illusion was especially brought home to me as an outsider on two occasions.

A few years ago I climbed Ben Nevis. I discovered that I had lost my Asthma inhaler and (typically for me) forgotten to pack a spare. Armed with a smart phone I quickly ordered a new inhaler prescription privately through a national Pharmacy chain’s website, and paid for the prescribing service. I was very grateful. Driving back to London for an inhaler was out of the question, going to A&E seemed a waste of resources and time, I was delighted to pay.

We went to pick up my medicine which was waiting locally in the same brand pharmacy that I had paid online in Fort William. When I went to pay, the pharmacy assistant proudly refused payment, stating that in Scotland there was no prescription charge. It struck me then how unbelievably wasteful and unfair it was. I was effectively a foreigner twice over, living in the UK under indefinite leave to remain visa, and having paid my taxes into the Sassenach Treasury, as yet the Scots woman was proud to spurn my payment.

The other occasion was the 2012 London Olympics Opening ceremony where a dance routine in which a phalanx of nurses twirled legions of pyjama clad patients on wheeled metal framed beds. Before I proceed to attempt to extract the cultural meaning from this, let me say I am very aware of the difficulty British people, specifically English people have with national symbols. I was made aware of this in the story of a 1970s Miss World contestant from England who for the national costume section of pageant resorted to wearing a Beefeater uniform.

I am I must concede not a connoisseur of Olympic Opening ceremonies. They are, for all the colour and “drama”, in my eyes they are very little removed from North Korean Revolution day march-pasts where precision, uniformity and smiles of rictus rigidity and intensity are compulsory. Perhaps Olympic ceremonies are without the Korean threat of pain of death for missing your cue. But the essential appeal to communality and definitive identity are there. That the British choreographer reached out to such a quotidian and quite literally morbid institution as the means of delivering healthcare is more revealing about British culture than I think Danny Boyle meant it to be. Discussion of the NHS with some British people is almost as fraught with difficulty as a discussion on the divinity of Kim Il Sung is with a North Korean. Such a discussion follows the logic: it is, but of course it isn’t. However, it really is and if it proves not to be the universe will obviously end. Complaining about the NHS is almost compulsory, however critiquing it is met with accusations of wishing for a Hobbesian free-for-all, or worse still the American system.

Just because no money changes hands, doesn’t mean you don’t have an economic relationship with the NHS.

So what effect does the illusion of the abolition of the economic relationship between patient and practitioner have? If the patient isn’t the doctor’s or the nurse’s client, who is? Well, ultimately it is the Minister for Health who loses his job if an NHS scandal is egregious enough to stand out from the jostling multitudes of Red-topped tabloid scandals that flow in an unending river. It is the Minister who also signs the budget. However, the Minister can only be interested in aggregate. In effect, it is the Administrators and Chief Executives of NHS Trusts who really are custodians of the patient’s aggregate economic power in their relations with doctors.

Outside of their own professions, the practitioners within the NHS look toward the Administrators of the hospitals and their priorities. And their priorities while aligned as best as they can make them with the patient’s, are not totally identical. In economic terms, there remains one vestigial power available to the patient, both at the personal and institutional level: the power to complain. And the NHS is shaped around these two competing methods of resource distribution: Administrators targets and patient complaint. NHS doctors and nurses negotiate around these two pressures and it is a testament to their dedication and professionalism that they are able to make the hospital work.

Another factor haunts the relationship and that is the absolute level of resources available within the NHS. As the practitioner fights the system to get the best they can for the patient, and they do fight as hard as they can, the best the system can deliver is often slow and frustrating unless you are dying, and sometimes even then. That is because the distribution of resources that is most efficient for the NHS to the aggregate patient population is often unfortunate for the individual. The practitioner is often faced with delivering the slow, the frustrating service, and if you were they wouldn’t you dissociate yourself from the service you deliver? “You can’t expect to come into the NHS on a Sunday night and get an operation.”

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Accident in the Pyrenees

When we first arrived in Europe I was 29 and my partner and I travelled into the Spanish Pyrenees in late spring to give me the opportunity to climb Pico de Aneto. It is the highest mountain in the chain and one of the few places where the glaciers remain. We stayed in for us a magical mountain village named Benasque that was unlike anything Jacquie and I had ever seen. I hired a guide and we started at oh-god-it’s-still-dark in the morning. However, as we drove to the end of the road the foul weather thickened into snow and we turned around before I even saw the mountain.

Sixteen years later I returned with my climbing mate Dan with plenty of time to reconnoitre and plan. The guide books said 6 hours up and 4 hours back from the hut called Renclusa. After a restless nervous night, Dan and I got up before 4am to get an early start and off the mountain in time for an afternoon beer.  Starting from the bottom and the stumbling through dark armed only with a single AA Battery torch because we had overlooked to check our headlamps before starting, we followed the path to the hut. Just after the hut Dan discovered a way to make his headlamp work. Which was just as well as the path petered out and we picked our way through the blocky terrain. We pursued the strings of walkers and climbers above festooning the crepuscular mountain like Christmas lights.

At about 9.45am, having not yet reached the snow line I expressed doubt to Dan whether we would make it to the top. We and the surrounding groups of mountaineers couldn’t find the pass, Portillion Superior which would take us to the glacier in the early morning half light. Finally, a couple of hundred feet beneath us the small breech in the ridgeline was identified and I looked down onto the path to the peak. Instead of snow fields or nevé, there was a seemingly endless field of boulders from brick sized to house sized. This form of torture glories under the name talus.

Talus is a feature of granite geology. In New Zealand the mountains are predominantly made from a form of geological Weetabix affectionately known as greywacke. Between the friability of this form of sandstone and the constant seismic activity, there’s a reason why Kiwi mountaineers are known for their ability on snow. Europe is covered in granite, particularly in the Alps making the best and safest routes often on rock, away from the threat of avalanche and crevasse. As granite is a strong regularly crystalline rock, when these mountains erode they fall into cuboid blocks with regular edges rather than the sweeping fans of shingle scree than make up the flanks of many New Zealand mountains.

Talus, I hate the stuff. Being of the short-legged and squat-formed variety of humanity, pitching from wobbly balanced block to funny angled slab is not my idea of fun. Going up was heavy going, but coming down was horrible and concerning. Tiredness made things worse. Dan is more nimble than I and lead the way down. I asked him to stay within screaming distance for when I broke my leg. He asked me not to say that as the jinx frightened him. We crossed the pass back to the slopes above Renclusa. As the lumps of granite got smaller things actually became trickier. About three hours above the hut, on a left diagonal traverse descent, I put my right foot on a block, it wobbled and I leaned left to stop pitching down the mountain. I stuck my left foot out to nothing and fell a couple of metres sideways and down making contact on another block with my bent elbow, before coming to rest in a groove between blocks, my boots pointing uphill and my head down.

The sound of dry cornflakes crunching under a boot within a liquid medium meant that I knew instantly that I had a fracture and not a clean break either. I also knew it was both the radius and ulna from where the impact had been. I don’t remember it being horrendously painful either. It did ache and occasionally if it was moved it would let me know I was being foolish. So when I turned myself around so that my head was on the upside and my left fractured arm was supported above me on the sloping slab next to me it was surprisingly not agonizing.

Suddenly I was surrounded by concerned faces. Frattura! Frattura! I urged those around me not to grab my left arm. To this day I haven’t looked up what the Spanish for broken bone is, but it seemed to work. A confident woman pointed out the blood emanating for my arm and told me she’d have to take a look at the wound just to make sure I wasn’t hiding a spurting open artery. No-one had scissors. Someone produced a knife and with a ginger lifting from me she proceeded to open the long sleeved woollen t-shirt from the cuff upwards toward the wound.

Can you see bone? I asked in broken Mediterranean indeterminate romance language. No, she replied. No bone. Relief passed through me. Without really trying, I had rehearsed all the worst possible outcomes in my mind. She pressed some cotton wadding onto the wound and I lowered my arm to give some pressure.

Okay, I said. We need to bind my arm to my body so that I can walk down to the hut. No, no, no. Everyone thought that that was a stupid idea. It was. I don’t know whether it was bravado or a little bit of panic or, if the reader will indulge me, the self-rescue ethic imbued into Kiwis when they’re in the great outdoors. Dan told me that some of the climbers had hared down the mountain to Renclusa to call the local emergency helicopter. It’ll be here soon.  No, I said, it’s going to be hours. It’s fine, but it’s going to be a little boring for you.

A nice young Catalan couple volunteered to stay with me and Dan during the wait for the helicopter. Dan and they talked in great expressive English about the landscape, Catalunya and Spain and the forthcoming referendum in Catalunya about secession from the Kingdom. Between bouts of the violent shakes from shock, I listened into their conversation. It was bright and sunny, but in the September shadow it had started to turn cool. I tried not to think about how soon the sun went down.

I got bored and started to sing John Denver songs. I thought it was whimsical, but later Dan said he believed he could hear in the aggression with which I hit that the notes of Country Road the scale of the suffering I was enduring. It’s difficult to know. You forget pain, so that in retrospect your behaviour seems odd and disjointed without the context of the mind altering distraction. The young Catalan man asked me if I knew any traditional New Zealand songs.

I started in on E Pari Ra, of which I know a single verse and so progressed to Pokere Kere Ana. These songs are remnants of embarrassed school assembly mumble-alongs, but now a point of pride that I can produce some authentic NZ culture if asked. The Catalan guy asked me what the song meant and cheerfully I told him that in the song a Maori princess calls to her lover across Lake Rotorua as he swims at night to visit her…But he drowns and…I’m struck by a sudden emotional convulsion. Homesickness washes over me and I blub. Surprise and mild revulsion at this self-pity make me struggle silently against the tears. I internally thrash around for a means of pushing away the sorrow or at least this quivering expression. I feel humiliated by my tears. It’s foolish and it’s emotionally stunted and I want to be free with my feelings. But I am a Kiwi boy and I am what I am, and to deny this is an equal suppression of my essential self.

I start Te Rauparaha’s haka (the one performed traditionally by the All Blacks) in an effort to re-establish self-control. Kamate kamate…the young Catalonian whooped with pleasure. I realise that when he asked for traditional NZ songs this is actually what he wanted. I roll my eyes and the syllables explode out of me and the sadness becomes aggression. Ka ora, ka ora…

After a second repetition I slip into silence. Songs that I like will overwhelm me with emotion. There is nothing to say. I feel Dan’s discomfort at not being able to do anything while we wait. We wait in the afternoon sun.

I think Dan hears the rotors of the helicopter first. From my position I don’t see it until the helicopter is circling above us. There is nowhere to land. I imagine myself being winched into the chopper either in a harness or in a metal stretcher euphemistically known in the skiing community as a blood bucket. The helicopter is noisy and kicking up a lot of wind, so I’m clutching at the parkas laid over me to prevent them from disappearing with my eyes closed. I’m genuinely surprised when I see crouched over me two emergency medical rescuers in their bright orange overalls, mountaineering harnesses and helmets. Neither speaks any English. The Catalan woman crouches over my head translating.

I’m only hurt in my left arm. I can move my legs, see? I’m asthmatic. No, I haven’t had a head injury. I shout these answers and they are translated in shout from the woman. Finally the rescue medic explains that there is a doctor at Benasque. They can go get him if I think it would be better or I can just get into the helicopter and get it sorted out down there.

Fuck the doctor, I shout. Fuck el medico, the woman translates. But she needn’t have had. He knows exactly what I meant. They can’t take me from the spot I’m lying. There a big flat slab about 20 metres away downhill. Can I make it? Sure, let’s go.

I get to my feet and find that the only thing I can do with my left arm is to let it hang straight down. Moving feels nasty, but I want off the mountain. Moving from block to block, without jumping is difficult. Jumping means agony for my elbow. At one point I hesitate a few times over a big step down and one of the rescue medics in an effort to help holds my lower arm as it dangles. I look him in the eye and scream in pain as loudly as I can over the helicopter’s noise. He understands and let’s go. We get down to the block and one of the rescue medics motions me down. I get down on my hand and knees. My eyes are closed and the wind helicopter noise is deafening. I wait for one of the medics to wrap the harness around me.

Instead I feel a tap on my shoulder. I look up and the helicopter pilot has placed one skid on the edge of the flat block we are perched on and is hovering with the other skid in space. Before I could be properly impressed, I take 2 steps and I am inside the body of the aircraft.

The chopper lifts and banks down the slope out into the clear space above the valley. It’s a clear run, but I’m hit with motion sickness. Una bolsa!, I shout at the rescue medic. He looks confused as to why I would want a bag and points quizzically at my rucksack. I mime throwing up and suddenly the entire 4 man crew of this helicopter is desperately searching for a receptacle. The hunt turns up nothing of use, and the rescue medic leans over me and opens a 10cm by 10cm slider in the window next to me to give me something to vomit through. I swallow hard and think about the effect of cloud cover on the movement of a cricket ball.

It isn’t long before we land at a grass landing field just outside Benasque. The engine is turned off and as the rotors slow to a stop the rescue medics jump out and the pilots see about refuelling the helicopter. I feel slightly forgotten still strapped to my seat, when the doctor comes aboard to examine my arm. He asks me some questions most of which I’m able to answer in Spanish. He asks me something that I can’t understand and the pilot in perfect English explains. I’m aware that the entire crew surrounds the aircraft doing demonstrably manly things.

The doctor pauses. I suppose I should offer you pain management. Would you like Fentanyl? Fentanyl is a synthetic opioid about 40 times stronger than morphine. In the flight down I had been so relieved and become so relaxed in the helicopter seat with my arm dangling beside me, I honestly had no pain 0/10, if I didn’t try to move it.

Fentanillo? Por esto? I said pointing at my elbow. No! The crew erupted in simultaneous approbation, in a fine display of Hispanic machismo. While I appreciated the support I also felt foolish that maybe I too was being machismo. The doctor gave me the opinion he didn’t think it was broken, but just a very bad sprain. I was surprised, but I believed him. Part of me suspected that I had been making it up all along.

I turned on my phone to text my partner Jacquie. Over the twenty something years together she had endured my infrequent but seemingly regular visits to the hospital: pneumonia, knee injury, fall, allergic reaction, hip injury. The message or telephone conversation always starts, I don’t want you to worry but…It has become such a cliché that I use it now to signal I’m in or going to hospital. I took a photo of the pilot giving a thumbs-up over his shoulder in the helicopter and told her what was happening. I asked her to text Dan as to where I was going.

We were in the air again taking me to Hospital in Jaca. I had been given a headset and the pilot chatted to me in English. He was going to London in a few weeks to practice his English and pick up girls. I told him he’d be lucky to find someone to speak English with as it seemed every other person in London spoke Spanish. He agreed it had been a problem in the past. And the relative abundance of Hispanic male talent in London had undercut the value of being mysteriously foreign in a smouldering Latin way.

We landed on a football field within the military base at Jaca and there was an ambulance waiting for me. It was a little difficult getting into the ambulance and sitting with the arm now becoming more painful and punishing me for every ill-considered movement. It would not fit if I let it hang next to me in the ambulance so carefully I bent it with my other hand and laid the hand in my lap. That was the last time my arm was straight for months.  The driver took the route slowly. Is it far? I asked. Just 2 more blocks he said. He slowed to crawl and went wide around a large ugly pot hole. Muchos gracias, I called. De nada. He pulled up to the entrance and got me into the wheelchair. My details were taken at reception and I was wheeled straight to the waiting Emergency doctor, two nurses and I guess either a trainee nurse or a nurse aide.

After establishing that my Spanish comprehension was a little more extensive than her English, we went through the details in Spanish; age, occupation etc. She complemented me on being an osteopath which I thought was kind if only to be polite. She looked at the wound and ordered a canulla and fentanyl (this time no buts- the benefit I suppose of having a woman doctor). The nurse cut the rest of the shirt off me and put in the canulla. I have from experience elusive veins, so when the canulla hit its mark first time I complemented the nurse on her skill. The nurse looked to the doctor, what does he mean? The doctor replied, he’s an osteopath, he knows about these things. It may have been for my benefit, but I started to believe that this doctor’s opinion of my profession was actually higher than my own.

An x-ray needed to be taken. The orderly, a really smiley guy called Pepe came and wheeled me on a gurney to radiology straight into the x-ray theatre. My doctor was waiting for me when I arrived and introduced me to the orthopaedic surgeon. There was another older doctor there to whom they deferred but to whom I wasn’t introduced. I assume he was the senior consultant.

My emergency doctor explained that she needed to get my arm in a position where the two bones of the lower arm the ulna and the radius would be close to parallel so that they could see the damage to either and both without the other obscuring. I could make as much noise as I liked but I couldn’t move and I had to relax my arm. The older doctor held my right hand and told me to squeeze it as hard as I liked.

I’m not ashamed to say I screamed and hollered and huffed. I concentrated hard on letting go of that arm but it fought her all the way. Finally she got my arm into a position, but she couldn’t let it go as it would have snapped back. The technicians wrapped her in a lead apron and sleeves and put a helmet and visor on her and they took a snap. Was it clear? I asked. Perfecto.

Pepe wheeled me back to emergency consulting room. The nurses greeted me like an old acquaintance. I got off the gurney and lay down. As I relaxed into the table to wait my eyes started to stream out of the corners and down my temples. I was too tired to pretend I wasn’t scared and in pain. I didn’t sob, but I certainly cried. The older doctor came in and noticed my tears. He took a tissue and dried the corners of my eyes and told me quietly I was very brave. I was enormously impressed at that moment at his humanity and his professionalism. It is a moment of compassion I will never forget. It is a moment I will use to model my behaviour as a practitioner from this time forward to honour him.

My emergency doctor and the orthopod came to talk to me. The x-ray was as bad as they thought it would be and it could only be worse if I had actually smashed the joint itself. The ulna and the radial head were a jumble of pieces. The orthopod said if it were up to him he’d put me in for surgery that night and he would most likely replace the radial head with a prosthesis. What did I want to do?

Pico de Aneto was the only time in my climbing career that I had forgone insurance. Through underestimating the risk and absent mindedness I was uncovered. As a non-national resident of the EU, I had no idea if I was entitled to reciprocal healthcare in Spain and I figured that I didn’t. I could only think of the cost.

Wrap it up and send me to London. My friend is on his way, we’ll drive to Barcelona and fly to the UK. The orthopod smiled and immediately they began preparing my arm for a half slab cast. The fact that it was a half slab later turned out to be important. The emergency doctor told me that I was being admitted tonight for pain management, to be fed, have a sedative for a good night’s sleep and I could go tomorrow. Again she said it in a way that brooked no challenge and which I found reassuring. She knew what was best for me and I knew she was putting my interests first.

In the pause after applying the cast one of the nurses asked me if I wanted to see my x-ray on the computer screen adjacent. Yes, please. Can I take a picture with my phone?

Give your phone to me I will take it to make sure it comes out. There, what do you think?

Jesus! I thought. Gracias, I said and texted the image to Jacquie.

On arrival to my own room on the ward, dinner was waiting for me. Garlic chicken consommé (Sopa). Cod fillet and mussels, vegetables. Creme caramel. Apple. Mostly bland, but well and attentively cooked. Again I was surprised. My nurse came to see it I was alright, followed by the orthopod and emergency doctor. I had lost track of my passport and wallet. A quick text to Jacquie established the word for wallet was billeteria and I asked. The nurse opened the sweaty plastic bag full of my smelly clothes and retrieved the items. Algo mas? No gracias, nada mas.

The next morning after an unexpectedly reasonable night’s sleep, the nurse offered me a shower which I gratefully accepted. I’m not shy, but when it comes to washing my junk I prefer not to have other people involved. I learnt the Spanish word for undercarriage and got through the process with some dignity intact. It was my first assisted wash and it became a benchmark. Assisted washing like many nursing processes is a necessary mix of humbling and humiliating. The skill of the nurse is to tip it toward humbling and away from humiliating.

Dan texted he was close by and the orthopod came to discharge me. He wrote up a description of the lesion and a summary of care in Spanish complete with a CD of my x-ray for the admitting doctor in the UK. Dan arrived and he dressed me and we walked out to the hire-car. While it was very painful to jolts, I was pretty comfortable considering. The drive to Bracelona where Jacquie had booked a flight for me that evening was uneventful. Dan and I talked the usual rambling road-trip conversation.

When I arrived at check in with Dan the agent saw my cast and told me I couldn’t fly. We wheedled and argued, but she stuck the rules. No-one with a cast less than 48 hours old may fly. Dan being American asked to see the Supervisor, and I was grateful he did. The Supervisor wearily repeated the rule. But why? Because if the arm swells at altitude, the airline won’t be held responsible for the damage to the arm. Ah, but you see, it’s only plaster on one side. On the other, it’s bandages. I offered the inside surface of my arm within the sling to the Supervisor. On touching the soft bandaged arm he agreed I could fly. The doctors in Jaca knew what they were doing and so did Dan.

MORALS OF THE STORY

There are a number of themes that repeatedly come up in this story and a few that start from the very beginning. The first is the Stockdale paradox. This is the attitude of mind that holds simultaneously an unshakeable belief that you will survive you current predicament with a pragmatic pessimism of early or easy change in the current bad conditions and acknowledging one’s powerlessness to alter one’s situation. It is named after an American naval officer captured by the North Vietnamese in the Vietnam War who went on to become an admiral and a running mate to Ross Perot in the presidential elections. As a ranking officer in the Hanoi Hilton POW prison, he was singled out for torture and led the resistance of the American prisoners through personal example.

He noted that the optimists within the prison, those who would say “we’ll be out by Christmas” were the ones who eventually gave up hope and had their will broken, often fatally. That attitude made the believer a hostage to fortune. If the relief did not arrive it required an effort to construct another target for hope. It’s a pattern that can be found again and again in survival situations such as Shackleton’s remarkable escape for the entire ship’s company in the Endurance expedition. Shackleton himself became the focus of the Expedition’s hope of survival, despite he himself continually lowering the expectations of his crew and asking them to endure extreme privations and strenuous daily efforts.

Indeed the Outward Bound movement was partly based on the observation that in survival situations that it wasn’t the young and physically strong who survived shipwreck, but those who had been at sea for years and particularly those who had been shipwrecked before.

If you find yourself in a particularly bad predicament of any sort, you have to have the conviction that you’ll get through it. Lowered expectations of how easy or quick it will be insulate you from having your will broken. Thus the paradoxical balance between seemingly contradictory long term and short term beliefs maximises your chances in the long term.

When you are hurt, in pain, and fearful, you will eventually cry. Better accept it whatever your cultural beliefs or natural inclination to courage and fortitude. To a certain extent it’s better to get it out of the way so that you don’t spend so much effort avoiding it.

When it hurts enough, cry.

Pain is context dependent. Pain is a subjective experience. Wittgenstein observed that subjective experience is like a beetle in a box, and only you may look into you own box. Everyone has a beetle in a box and we can describe it to each other, but we’ll never really be able to compare. This makes it extremely difficult to really relate our pain to another person. Every working day I ask patients where in score out of 10, where 0 is no pain and 10 is having their leg sawn off with a rusty spoon, they would rank their pain. It is not uncommon for the patient to not be able to. Not because they lack imagination, but because it is an outlandish and artificial proposition to measure suffering even relatively.

I remember the exhilaration of relief to be off the mountain in the helicopter talking to the doctor. I felt no pain. It took 45 minutes to realise I was still in tremendous pain.

When offered pain relief, take it, even if you think you’re not experiencing pain.

 

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