HEALTH UPDATE – PRE-ASSESSMENT APPOINTMENT
Today I attended the hospital in Exeter again, for the pre-assessment appointment with the anaesthetist, prior to my parastomal hernia repair and proctectomy. I saw the new consultant colorectal surgeon (No. 3 since being referred to Exeter from Torbay back in 2018) in August of last year and have been waiting ever since to hear something.
A good appointment
It was a very fruitful appointment. The anaesthetist was thorough, and also listened to everything I had to say. The meeting was structured and covered everything necessary. He appreciated the fact that I had brought in typed summaries of a) my pre-Exeter history, b) my history since being referred to Exeter, and c) copy of the letter from the anaesthetist to my surgeon in Torbay after my pre-assessment appointment for the operation which took place in the spring of 2018. This was the operation which resulted in post-operative sepsis and the associated failure of the hernia repair. They should have had all this information in my records already because I have been through all this before, but to have it summarised was helpful.
The anaesthetist took photos of all three documents in order to upload them to my electronic notes.
My day-to-day life and how my ME affects me
He asked me for details about my day-to-day life, how mobile I am, what adaptations I have in the house, etc. I told him I only use the wheelchair when going out, which isn’t often – my husband has to take me and I am at home most of the time. At home I am mobile with my trolley and I am on my feet quite a lot, particularly in the mornings when I try to get most of my work done, spending the afternoons either on the recliner or sitting in my studio. He asked how much help I needed from my hubby and I told him I was pretty dependent upon him for many small daily things. I told him that I was on standard rate for daily living and enhanced rate for mobility categories of PIP. From this information he was able to judge how active and independent I am on a daily basis, which gives a baseline of my general health which will affect how well I do with the surgery. I also informed him about my change of diet a few years ago to whole-food plant-based, and how this has improved my health generally.
The risks of major surgery
We had a long discussion about the various risks to be taken into account for what is going to be major surgery. He told me that in view of my age since the initial operation back in 2015 when I was 61 (10 years ago), this upcoming operation would be on a par with that original one in terms of how seriously it will affect me. I told him that I was aware of how big a deal this was, and I was prepared for that. He told me that in view of the fact that I had a coronary artery spasm back in 2014 and also have left bundle branch block, they would be concerned about my heart. I had blood taken before I left, to check my haemoglobin levels, and because he wanted to check for elevated levels of a certain protein which would indicate the early onset of heart failure; if this is raised, he will order an ultrasound scan of my heart. He said there was no point in getting this done if the blood result was normal. The waiting list for the procedure is quite long and would just delay things further.
He was also concerned about the PEs found in 2016, resulting in my lifelong prescription of the anticoagulant rivaroxaban. My relative lack of mobility is a higher risk factor for developing blood clots. I pointed out to him the difficulties I have had in the past, being unable to sit out of bed for the required length of time in order to prevent DVTs, and asked specifically for the boot pumps and airflow mattress which I had had in the past. I said I would have no objection to sitting out of bed in my wheelchair (the hospital chairs are impossibly uncomfortable for me) for shorter but more frequent periods if this would help. I understand the risks of spending too much time in bed.
Although I have done well in the past with my various operations, I am now older and this increases the risk of complications, with a longer recovery period, and rehabilitation post-operatively. After my last operation I noticed quite an increase in muscle weakness and lack of mobility but this soon returned once I was up and about, and especially after I returned home.
My stay in hospital
The operation is a big deal and I will apparently be the only case of the day. Exeter does not have a high dependency unit for the immediate post-op period so I will be spending 2 or 3 days in intensive care. He told me that the demand always outstrips the capacity, and I expressed concern that I would get postponed yet again, and he said it should be OK if the bed was booked in advance. He appreciated that I had been waiting six years now, since my initial referral at the end of 2018, and apologised for all the messing about that I have experienced. None of this has been the fault of the medical staff, but only the administration. It seems that the computer system is now working a lot better so hopefully there won’t be any further mix-ups. Of course, we are dealing with hugely long waiting lists generally on the NHS, exacerbated by Covid, but I do think six years is far too long to be waiting for elective surgery.
It is estimated that I will be in hospital for about a week, but that depends on how things go and how well I am after surgery.
Analgesia
Regarding analgesia, I shall be having an epidural, with the catheter being inserted immediately before the anaesthetic is administered. This is because I need to be conscious and able to sit with my spine bent over. He told me that this is not a painful experience as a local anaesthetic will be administered first. I should experience very little loss of sensation and weakness afterwards as the drug targets the smaller nerves involved with the sensation of pain, leaving the larger nerves more or less untouched. After the epidural is removed, I will be on oral analgesia, a combination of paracetamol and oral morphine, and may not need the morphine pump. Obviously my pain levels will be monitored and dealt with accordingly.
Cannula problems
I informed him of my concern about the problems I have experienced in the past with cannulae, which he also read about in the hospital letter of 2018. The chemo I had in 2015 has damaged my veins which tend to tissue over and cause the cannulae to fail. This problem was solved in the past with the insertion of a PICC line. He said that I would not be having one this time, but instead, a central line, inserted while I am under the anaesthetic. In view of the risk of ileus resulting from the handling of my small intestine, I would also have a nasogastric tube inserted, and I was reassured to know that this would also be done while I was under the anaesthetic, as my experience of having this inserted while awake, back in 2017 when I had my obstruction, was sheer torture and I wasn’t prepared to go through that again!
Other interventions
Other interventions would be the normal urinary catheter, and also initially, an arterial monitor on my wrist. I had one of these after my first operation back in 2015, just while I was in the recovery room overnight and before I was transferred to the main ward.
Blood transfusions
I asked him if I was likely to need a blood transfusion, and he said it was unlikely. In the event, I requested that I have my own blood taken in advance to be used. He knew about this and said it was possible, but that procedure in itself could be risky for me, depleting my haemoglobin levels, and in view of the fact that I had had a coronary artery spasm, could even bring on another one. In view of the low risk of needing a transfusion, it could be unwise to put myself at this greater risk. He said it would be possible to give me an intravenous top-up of iron if necessary. Everything rather depends on the result of today’s blood samples.
Risks specific to me
He asked me if I knew the cause of the coronary artery spasm, and I told him it was almost certainly due to stress. We were having a very difficult time with Mum who was living with us at the time, and I was undergoing considerable stress as a result. I was given a GTN spray to use if I had further symptoms but I told him I only had to use it a couple of times, and after Mum had gone into residential care and things calmed down, I have not used it since. I count this as a one-off incident, but the fact that it has happened once means that it could happen again, given the right stressors on my heart, whether physical or psychological.
As far as risk is concerned generally, they would be looking at my heart, the possibility of chest infection if I am immobile in bed and not breathing deeply enough (I said I would make a point of trying to breathe deeply), post-operative wound infection, and UTI. These are all risks associated with major surgery generally, but in view of my age since my last operation, these become more concerning.
Conclusion
The purpose of the pre-assessment appointment is to evaluate all the risks in view of my history and current medical condition, so that they can prepare in advance as much as possible for the best possible care for me as an individual while I am in hospital. I had brought along a sheet of questions, and at the end of the interview I asked if I could run through the ones that had not already been covered, but when I started, he stopped me and said that any practical concerns could be discussed nearer the time with the nurse, and with the surgeon on the day of admission. I was happy with this.
I haven’t weighed myself recently, so yesterday I got on the scales and was disappointed to see that I have gained quite a bit of weight. I do not have a date for the operation yet, of course, but it probably won’t be for a few weeks, and I am now taking measures to try and lose at least a few pounds before I go in, as this can only positively affect the general outcome and reduce any risks. I am not seriously overweight but would like to get my BMI down a little!
I have been down this route before, three years ago. I had a pre-assessment appointment and was given a date for surgery, and was even sent home with the energy drinks one has to consume before being admitted. Shortly after that, I was informed that everything had been cancelled, so I was back in the waiting game once more. This time, I shan’t assume anything. I haven’t got a date yet, of course, but I shan’t believe it is actually happening until the general anaesthetic is being injected into my arm!
Update – 21st March:
On my “MyHealth” page I now have access to my blood results from yesterday. Everything is normal so I shall not be requiring the echocardiogram, which is a relief. There was also a copy of the letter the anaesthetist has sent to the surgeon, summarising yesterday’s appointments, and apart from one or two very minor errors which won’t affect anything, everything was summarised satisfactorily, and my major concerns (e.g. cannula problems, and not being able to sit out of bed for extended periods) are now in writing and hopefully will be dealt with accordingly.
