Richard

Meet Richard

Richard is 87-years old and has a bad right hip. Apart from this, Richard is fit for his age. He was very active until about a year ago when his hip started to cause increasing pain and limited his movement. He has had to give up bowling, and is finding it hard to dress, in particular to bend over to get his socks on by himself. More important to him is that he is unable to work in his beloved garden.

“When my wife died 20 years ago, the family was keen for me to move, but I didn’t want to leave my garden. I still enjoy pottering but now I can’t even bend down to pull the weeds out. And what would I do in one of those retirement villages? No, I’m better off here in my own house.”

Richard had tried several types of medication from his family doctor who finally suggested that a hip replacement might be the right course. Richard’s last experience of surgery and anaesthesia was 40 years ago, when he had an operation on his nose.

“Polyps,” he recalls, “not very pleasant.”

At first, Richard was unwilling to consider having a hip replacement, being conscious of his age. No doubt in the back of his mind he was also thinking of his dear wife who had contracted pneumonia and died after having her gall bladder out.

“She had been her usual sprightly self when she went into hospital but never came home again….”

Preparation

Richard’s family doctor made an appointment for him to see an orthopaedic surgeon, who reviewed Richard’s history and examined him.

“You’re incredibly fit for your age – if we fix that right hip, we’ll have you jogging in no time. Mind you, the likelihood is that you’ll have trouble with the other hip within the next few years too, but at the moment it’s doing fine and we shouldn’t worry about it.”

The surgeon explained in detail how an artificial hip works and showed Richard an example.

“That all looks fine,” said Richard, “but I’m not a young man and I’m not too sure about the anaesthetic and how I’ll be after the operation.”

The surgeon replied, “I understand your concern. That’s why I like to arrange for all of my patients to be seen by an anaesthetist ahead of time.”

Richard makes an appointment and duly attends the Pre-Anaesthetic Clinic two weeks before the proposed date of the operation. This time, his daughter, a former nurse, comes with him.

The anaesthetist ushers Richard and his daughter in, and goes through Richard’s history. He then examines his chest, listening with his stethoscope, and measures his blood pressure. He examines Richard’s throat and the mobility of his neck and jaw. He also examines his hands.

“You are in great shape,” says the anaesthetist. “It will stand you in good stead. Are you allergic to anything?”

“No,” replies Richard.

“What about medications – you’ve been on a few anti-inflammatory drugs, haven’t you?”

“Yes,” said Richard, and reels off a list of painkillers and anti-inflammatory drugs he has been taking.

“Any trouble with your stomach – with ulcers or heartburn?” asks the anaesthetist. “Sometimes those drugs play havoc with your insides.”

“No, not that I’m aware of.”

“Any other medications?”

“Just a sleeping pill – I started taking them when my wife died and I’ve been taking them ever since – just two a night.”

“What sort?”

“A little pink one – sorry, that’s the one I forgot to bring with me.”

“I didn’t know that you took a sleeping pill, Dad,” says his daughter, who until now has been sitting quietly.

“Almost forgot myself. I get into bed, take two, turn off the light, roll over and go to sleep.”

“Have you ever managed sleeping without them?” asks the anaesthetist.

“Oh no. I tried to stop taking them and it was terrible. I couldn’t sleep a wink and the family wondered why I was so grumpy. Probably should have tried harder to get off them – but it seemed too unpleasant.” His daughter looks at him sympathetically but says nothing.

“Well,” says the anaesthetist, “that sometimes causes a bit of a problem after anaesthesia in someone of your age. It’s like withdrawal and can result in some mental confusion.”

“I’m not sure I like the sound of that,” says Richard.

“Nor I,” whispers his daughter.

“We can help with other medications, but it can be a trying time for all, especially your family. Most patients who are a bit confused postoperatively don’t remember being so, and it doesn’t worry them as much as it does the family. We’ll have to keep an eye on that, if you decide to go ahead with the operation.”

“What about the anaesthetic – isn’t it dangerous to put an old chap like me to sleep?”

“In the past it probably was, but now with modern drugs and more information about exactly what we’re giving you, better equipment and techniques, we can very safely look after people like you for major surgery. Clearly, the older you are, the fewer reserves you have and the more likely complications are to occur. Things like heart failure, blood clots in the legs, bronchitis, and pneumonia are more common in older patients.”

Richard takes a deep breath and then says, “My wife died after an anaesthetic.”

The anaesthetist responds, “I’m awfully sorry to hear that. How long ago did she die and what was she having done?”

“She had her gall bladder removed 20 years ago – got pneumonia and never got out of hospital.”

“Well,” comments the anaesthetist, “things are certainly a lot better now. We didn’t  monitor oxygen then, except to observe if the patient was pink. We’re also much better at managing patients postoperatively. It’s not uncommon for patients after gall bladder surgery to have some difficulty with breathing after the operation, especially if they have to have the big  incision, instead of keyhole surgery. The problem is that the incision is right under the lung and every time the patient takes a breath it hurts. So you have an elderly patient, perhaps prone to asthma or bronchitis, who has her breathing and coughing restricted for a few days. Before you know it, pneumonia sets in – and it can be very difficult to diagnose and to treat. But today we’re much more aware of how to avoid and, if necessary, how to manage these complications.”

After a pause Richard asks, “What sort of anaesthetic will you use? I’ve heard of these operations being done under local.”

“What I would advise is an  epidural – the sort of anaesthetic we often use for childbirth.”

Richard’s daughter concurs. “Yes, Dad, you’d be so much better with an epidural.”

“I must say it’s easier when someone else is persuading the patient about epidurals. But you need to know a few facts before making up your mind,” the anaesthetist continues. “Having an epidural means that we’d put you on your side, wash off your back with some cold antiseptic solution, then inject some freezing into the skin in the middle of your lower back. That feels like a tiny insect bite. Then the anaesthetist will insert a long needle in between the bones of your spine until it reaches the epidural space. That shouldn’t hurt at all but you might feel some pressure sensation, which might be a little uncomfortable. You’ll need to lie very still while the needle is carefully positioned. Then a fine plastic tube is threaded through the needle and into your back. Sometimes the tube may just gently nudge a nerve – might feel like a small electric shock – like hitting your funny bone. The important thing is not to move if you feel that, but simply to tell the anaesthetist. Once the catheter is in place, the needle will be pulled out and you will be able to move a little. After the catheter is taped onto your back, a small dose of local anaesthetic is injected to make sure that the catheter hasn’t entered a blood vessel. Once we’re sure that everything’s OK, then more local anaesthetic can be injected down through the tube. That might feel like cold liquid running down your back.”

The anaesthetist continues, “The beauty of epidural anaesthesia is that we can continue using it for a few days after the operation to keep you really comfortable, without giving you large doses of drugs like  morphine. So, above the waist, so to speak, you can be your usual self.”

“What if it doesn’t work?”

“We always have the option of giving you a general anaesthetic – which we would be happy to do. But I think that your recovery will be a little quicker with an epidural. An epidural works in about 98% of cases and I can assure you your anaesthetist won’t allow you to suffer any pain during the operation. He or she may give you a small amount of  sedation, just so you’re not bothered by all the noise and lights, and so on, in the Operating Room. And if you have some favourite music, you can bring it with you and listen to it during the operation.

Now, did the surgeon mention you giving some blood ahead of time, so that you don’t have to receive anyone else’s blood?”

Richard turns to his daughter and asks, “Was that the appointment at the hospital or at the blood bank?”

His daughter answers, “At the blood bank. The hospital appointment’s for you to see the physio.”

“Good,” says the anaesthetist. “But you’ll still need to have a few tests, if you decide to go ahead. Do you have any questions or concerns, either of you?”

“I think I’m reasonably happy,” replies Richard.

His daughter nods. “I want him to spend a week or two with us when he gets out of hospital.”

“And who’s going to look after my garden?’ asks Richard, a little crossly.

“We all will, Dad, we promise. Even the twins will help.”

At the thought of his nine-year old granddaughters, Richard smiles again.

“Now remember to keep taking your blood pressure medications, and check with your surgeon about your arthritis tablets. But bring all your medications and tablets, even the non-prescription ones, with you to the hospital. About the sleeping tablets, we’ve got a couple of weeks before the operation. If you can perhaps break the tablets and just take one tablet each night over the next week and then maybe half each night of the following week, it would be helpful for all of us. If you have any questions or concerns over the next couple of weeks, please don’t hesitate to call the clinic.”

“Thanks, Doctor, I’ll remember.”

At the hospital

Two weeks later, on the day of the operation, Richard is admitted to the hospital. The anaesthetist who meets him in the Admitting Unit reviews the record of the pre-anaesthetic consultation and the results of Richard’s tests. He again outlines the anaesthetic options, in case Richard has changed his mind and now wants to have a general anaesthetic. Richard is still willing to undergo epidural anaesthesia. As for the sleeping pills, Richard has managed to get down to one tablet a night. The anaesthetist reassures Richard and his daughter that the team will keep that in mind.

The anaesthetic

The nurses have Richard change into a hospital gown – neither modest nor warm but very traditional. Soon an orderly from the Operating Room arrives with a trolley and Richard makes himself as comfortable as he can on the narrow, hard conveyance with the mind of a supermarket cart.

In the Operating Room, another nurse checks Richard’s  chart and his name-band and asks on which side he is having his operation. She notes that the surgeon who had also visited Richard a little earlier in the Admission Unit had used a marker to sign his initials on the skin over Richard’s right hip.

The anaesthetist arrives, greets Richard again, and proceeds to wheel him into the Operating Room. With the help of an assistant, the anaesthetist gets Richard to lie on his back on the operating room table. The assistant starts to attach some monitors – adhesive electrodes for the electrocardiogram, a blood pressure cuff on the left arm, and a  pulse oximeter on the left thumb. Meanwhile, the anaesthetist takes Richard’s right arm, attaches a soft rubber tourniquet to make the veins stand out, injects a small amount of local anaesthetic into the skin on the back of Richard’s right hand and then inserts a large  intravenous  cannula. Once this is in, the assistant hands the anaesthetist a plastic tube attached to a bag of clear intravenous solution, which is then locked onto the cannula. The assistant adjusts the flow and Richard can feel the cool fluid trickling into his vein.

The anaesthetist then asks Richard to lie on his right side and the assistant helps him to tuck his knees up as high as they can go. Richard has a bit of difficulty raising the right one.

“That’s why I’m having this operation,” he quips.

After having checked Richard’s position, the anaesthetist then removes the gloves he wore to start the intravenous and goes out of the room to scrub his hands. The assistant has covered as much of Richard as he can, while leaving his back exposed. He asks Richard if he brought his own music or if he would be happy with the surgeon’s choice.

“Hope you like country and western!”

A few minutes later, the anaesthetist re-enters the Operating Room, holding his wet arms and hands out in front of him with the arms bent up. Water drips from his elbows. The nurse who is scrubbed hands him a sterile towel with which he dries his arms. She then assist him to put on a sterile gown and gives him a pair of sterile gloves, which he expertly dons. He walks over behind Richard, saying that he will explain everything he does and will tell him before each step. He proceeds to do so, first washing off Richard’s back with antiseptic, draping sterile towels over and around Richard’s back, and then inserting the epidural. After this is well-positioned and taped in securely, the anaesthetist and his assistant help Richard to lie on his back again.

Over the next ten minutes, Richard notices that his feet and legs feel warm and heavy and then just seem to disappear as the epidural takes effect. The anaesthetist asks Richard how he feels.

“Fine, although I can’t feel my legs any more.”

“Good. I’ll just test how high the block is.” He takes a small square of cotton, dips it into some alcohol solution, and strokes the sponge on Richard’s right shoulder. “Just tell me when you can’t feel this as cold,” instructs the anaesthetist.

He gradually works down Richard’s chest until there is a noticeable change in sensation just at the belly button.

“Didn’t even feel you touch there.”

“Great,” says the anaesthetist. “We’re ready to get everything set up.” To his assistant he says, “You can ask the surgeon if he’d like to come down now and scrub.”

The anaesthetist then injects something into Richard’s intravenous line and the rest is just a vague blur.

After the anaesthetic

It is the second day after the operation and Richard still has his epidural in place. It is connected via a long fine plastic tube to a syringe pump. It is steadily pumping a small amount of local anaesthetic and  narcotic mixture into his back. He feels comfortable and is eating and drinking, although he doesn’t have a great appetite. The day before is a vague blur. Richard had been asking for his wife and making other strange comments, in between appearing to be perfectly normal.

His daughter arrives with a basket of fruit and is pleased to see that he is much better.

“Hello. How are you? Oh, what a wonderful basket of fruit,” says Richard brightly.

“I’m well. How about you?” asks his daughter in return.

“I feel really very good – can’t remember much about yesterday – must have had a good sleep. Did you call?”

“Yes, I was here, but you were having a really good rest,” his daughter replies with a slight smile.

The anaesthetist appears at the door not long after.

“You’re looking much better today,” he says.

“Am I? I don’t remember seeing you yesterday,” replies Richard.

“You weren’t quite yourself then, but that’s not unusual for someone of your age having a major operation. You just needed a good sleep.”

The anaesthetist checks the epidural chart with the nurse, noting any changes in dose. He then uses the alcohol soaked cotton wool to map the extent of the block or numbness.

“Excellent. Everything’s going well. We’ll keep the epidural in for another day and get you on to some tablets for pain before we finally remove the epidural catheter. The nurse will be getting you moving again this afternoon. We held off yesterday and now we don’t want those legs to get stiff or develop any clots.”

“I’ll be pleased when I’m back in my garden,” says Richard. “I hope someone’s watering it.”

“Don’t worry about the garden,” responds his daughter. “Let’s get you on your feet first.”