Writer in Residence

The Numbers Game

The Weekend - November 26^th- 27^th

In the UK there are approximately 1,000 hip replacement operations every week. My guess is that many Britons expect to have the operation sometime in their 60s or thereabouts, just as they expect to be wearing spectacles and having teeth crowned. I don’t get the impression that it’s like that in Italy.

The initial shock was the specialist at Trevi asking me why I had a hip replacement operation carried out at such a young age (67.) I was quite taken aback and tried to explain that the X-rays showed that I have virtually no cartilage remaining in my hip joint and was becoming increasingly less mobile, but I don’t think he fully understood. The reality is that when I am out and about locally in Italy, I see many more people walking with sticks – bent over and moving slowly, than I would have seen around the town in Tunbridge Wells. It seems almost to be an accepted condition that comes with age, like a State Pension.

Then I look at this amazing Centre and am blown away by the quality and intensity of the care. Last week there have been just 19 patients in the post-operational unit; there are a few more on the floor below, where they care for people with more complex conditions resulting from serious accidents. The 19 patients comprise 5 men, of whom I am most certainly the youngest, and 14 women. We are all here for 3 weeks of intensive physiotherapy, 2 hours every day, 5 days a week, with the morning sessions being 1:1 and the afternoon sessions being in groups of 3 – 5 patients. From the moment I arrived, the rules were set down: no movement without assistance, no getting out of bed to go to the bathroom, no dressing myself, no standing without shoes on my feet, no attempting to move around without my wheelchair. My crutches are kept in the exercise room and I will not be allowed to have them in my room until they are confident of my ability to handle myself safely. They keep on nagging me to the point that it becomes quite irritating. How did you get out of bed this morning? Who dressed you? You must stop leaning forward when you work on the computer. Don’t get out of bed without a pillow gripped between your knees….and so on.

By contrast the hospital back in Foligno imposed no restrictions whatsoever. Nobody objected if I staggered to the bathroom, clinging to furniture and door-frames; nobody offered to help me with my socks or slippers and my attempts at walking up and down the corridor were met with admiring remarks and encouragement.

In UK and the US the emphasis seems to be on rapid recovery. I have looked at several UK and US websites dealing with hip replacements and I am staggered to read things like:

“On days 1 or 2, most total hip replacement patients are given a walker to stabilize them. By the third day after the surgery, most patients can go home.”

Today is my 15^th day after the operation, and they are still rigid here about what I can and cannot do. On the other hand, I am virtually unaware of my wound/scar and have no pain at all when I stand to get in and out of the wheelchair.

Then there’s the matter of medication. The UK and US sites suggest that by day 5 the occasional paracetamol should be sufficient to control any discomfort. I am still having daily checks on blood-pressure, antibiotics twice daily and a nightly injection of an anti-coagulant into the stomach wall. Is this overdoing things, or does the UK NHS skimp and cut corners? I just don’t know.

In the exercise room, any walking with crutches is expected to be as upright, normal and steady as possible, and while it is tiring, it is virtually pain-free. I watch elderly women who have completed their stay striding out confidently, albeit with two crutches. So what’s the answer? My instinct says that this 3-week rehabilitation course is an extravagant luxury that I have been fortunate enough to be offered on the local health programme. We’ll see how I am in a couple of weeks’ time. The surgeon at Foligno predicted that I’d walk out of here without crutches…. Now that would be quite an achievement, and for all their cheek and nagging and bullying, I’ll be extremely grateful to the staff I leave behind.

Lop-sided

The Week,  November 28^th – December 2^nd

The intense medical attention continues: blood pressure, blood samples for analysis, body temperature,  pulse rate and, of course, as in hospitals everywhere, the close interrogation about bowel movements. When such constant, detailed attention is paid to my condition, you will understand that it was something of a shock when the doctor examining me one afternoon paused and asked, with a slightly quizzical expression, ‘Have you always had one leg shorter than the other?’ When you put this in the context of the fact that they’d sawed a chunk out of my thigh bone in order to fit the prosthetic hip joint, you can see that I wondered whether they’d misread their measurements. In fact, I remember that many years ago, my local chiropodist in Lincoln identified a slight difference in my leg length, and commented that very few people had legs exactly the same length. I decided against putting my Italian doctor’s mind at rest and replied ambiguously ‘Most people have some difference in their leg length.’ He raised his eyebrows and gave an Italian shrug.

I don’t know if they did correct the leg length difference in the course of surgery, because I feel unbalanced now, anyway. Balance is one thing that is drastically affected by this operation. Your body has to learn it all over again. I often feel quite dizzy as I stand up – though I prefer to think that this is the direct result of a severe drop in food intake combined with a total lack of alcohol. The nerves need to reconnect where the muscles have been damaged and it all takes time. We are not used to being patient and letting time move at its own pace; we expect quick-fix remedies, and the body doesn’t work like that when it comes to healing. I have spent a week trying to learn to slow down, rest, take naps and doze, but it doesn’t come naturally.

Physiotherapy is a mix of pain and pleasure. The morning session is one-on-one and most of the session involves deep massage around the wound area. I start stretched out on a work-bench the size and height of a dining-room table. The first sensation is one of discomfort, lying on a hard surface and feeling the muscles stretching out to the maximum. When the therapist starts I can hardly feel the fingers rubbing my muscles, and at other times I wince and squirm as she hits the spot. Then she starts to get my muscles working, getting me to press my legs downwards into the bench, or push my legs outwards. The challenges start when I have to move the leg that has been operated on. She tells me to raise it 45 degrees and it simply doesn’t move until she takes some of the weight in her hand. Then she gets me to draw circles in the air with my pointed toes and the leg simply doesn’t understand left, right, up or down.

All the exercises are designed to stimulate muscles that have been underutilised while I’ve been limping around back at home with a stick, or muscles that are adjusting to a new role now that the hip joint has been replaced. The exercises are never weight-bearing; - in fact the whole attitude to mobility is rigid. In UK they get you up and walking in a couple of days, but it’s now 3 weeks since my operation and here at the clinic in Trevi they still insist I move around in a wheelchair, and they keep my crutches in the Exercise Room for supervised walks.

After the best part of an hour on the bench, they bring me my crutches and allow me to walk, but this is not about my ability to move around, it’s about my ability to walk perfectly upright, steady, controlled, feet pointing perfectly forward, back straight and hips first – like a mannequin. That’s an awful lot to remember at the same time as thinking about balance and stability so it takes a few strides to get it all together. The therapists are true disciplinarians with demanding standards and run a constant commentary of criticism – head up – chest out – feet pointing forward – move both crutches together – take shorter steps – take bigger steps – shoulders back…..and so on, so that the 10 minute walk becomes quite exhausting.

We finish up back at the wheelchair and while the therapist whisks away my crutches I spin back to my room to rest and probably doze.

The afternoon session is in groups of 5 or 6 and involves exercises which the therapist supervises like a Sergeant-Major on the parade ground. We are scattered around the room, lying on individual workbenches, and follow a series of exercises that involve working both legs independently, and other exercises that develop lower back muscles. No nice gentle massage in this session, just work that brings tears to the eyes. After the best part of an hour, we again have walking practice with the crutches.

I think it gets easier, I think the walking becomes more sedate and better synchronised, and the greatest frustration is probably having to climb back into the wheelchair at the end of the session and spin off back to the room. Maybe I’ll be allowed to move around on crutches next week – I’ll just have to wait and see.

The Constant Chatter of Friends and Relations

The weekend – 3^rd- 4^th December

It’s Saturday and the clinic is deafening with the buzz of visitors up and down the corridor. Several of the patients came round this morning, wishing a cheery goodbye as they left at the completion of their stay, others have been whisked away back home for some proper food and a few home comforts and will return later. My taciturn room-mate, known only by his surname to one and all, was collected by his daughter after breakfast. I could never penetrate his thick Umbrian accent, but he had a ready smile and reminded me of Grancio, the contadino who share-cropped Dad’s vines and olives, with his wrinkled leathery complexion, slow, steady movements and fixed, friendly smile. He had brought a small television with him and this was permanently tuned to a constant output of game shows and news broadcasts, whether he was awake or asleep, or even in the room. Since went home the room has been blissfully quiet, though this does increase the sensation of solitary confinement.

The cleaners have now given the room a thorough going-over ready for the next resident. The cleaning both here and previously at Foligno is an eye-opener. It is literally on-going and meticulous. This afternoon they stripped the vacated bed of its mattress and started to deep-clean the bed frame and the mechanism that raises and lowers it. Finally, they reassembled everything and shrouded it in a clean sheet ready to be made up as and when a new occupant is expected. Everything in the room is cleaned on a daily basis, from skirting boards to door frames – and they do two cleans a day just in case they miss something.

This morning they changed the dressing on my wound but still won’t say when I’ll be discharged. They want the wound to be completely healed, so I’ll just have to wait and see how things develop day by day. I’ve spent the day catching up on Radio 4 – I hadn’t realised how much I had missed the intelligent banter and witty comedy – and I still have a couple of unread books in Fi’s Kindle. There’s no reason to be bored, though the routine inevitably becomes monotonous.

The one treat I can look forward to is that at weekends I will have a yoghurt as well as an apple for my dessert, and in this institutionalised existence it’s amazing how such tiny factors achieve great significance. I wonder if it will be banana flavour or strawberry flavour.