99 Days Between Dinner Parties: Notes from surviving a fall Shane BonettiΛ

Preface

This might be of some slight use to doctors, nurses, therapists, carers and

patients. It is a contemporaneous record of a 98 day orthopaedic

hospitalisation in Scotland in 2008. I visited the hospital most every one of

those 98 days, and communicated some of what I saw and heard, by e-mail, to

60 or so friends and family of the patient.

I have edited to reduce spelling and grammar and expression errors, to

eliminate personal details such as phone numbers, and to minimise

repetition. Otherwise, these are as sent, in distress and tiredness, confusion

and celebration, fear and anger.

This then is little more than that venial sin of literature, e-mails re-cycled.

The dramatis personae are the patient (Jo), her daughter (Kat), her son-in-

law (Noah), brother (David), and cat (Isla), and her stuffed toy panda bear

(Lola). My name is Shane, and it always has been.

I include the final section (“Endnote”) with some reticence. The inclusion

detracts from the redemptive spirit I sought. But it was written and sent,

exactly as it appears. To omit it would be dishonourable and untrue.

SMB, December 2008

Injury

(Day 1, Friday August 22) Jo had an accident. She fell from the St Andrews

pier to rocks below while conducting a friend on a tour of the town. She is in

Ward 17 of Ninewells Hospital in Dundee with a broken pelvis, but with no

head or neck or significant spinal injury. She retained consciousness

throughout the coastguard rescue and ambulance travel.

She had surgery on Saturday to put in place scaffolding to stabilise her

pelvis. She is due for major orthopaedic surgery next Thursday, with a

number of pins and plates to be inserted. She faces a predicted six weeks

complete immobilisation,and a significant period of rest and rehabilitation

thereafter.

Jo asked me to send this to you. Sorry to bring such difficult news by email.

(Day 3, Sunday, August 24) More information is available. Jo's pelvis is

broken in five places. The breaks seem reasonably clean on the x-ray. In

Λ aceintheholeproductions and the author.

addition her sacrum and elbow are broken. She has been given blood

transfusions to prepare her for surgery on Thursday. Jo is now on "nil by

mouth". The surgery on Thursday is of ten hours duration. The surgery might

not go ahead - Jo has some gastric problems and clearing them up will be

required before the ordeal of surgery.

Jo's pain is being managed more successfully than in the first 48 hours of her

hospitalisation. She is on morphine, among other things, and is significantly

more comfortable than previously.

As for the exact cause and course of events last Friday, matters are a little

clearer. Returning towards land on the higher or raised part of the pier walk,

Jo came to the end of the raised platform. She lost her balance stepping down

to the main part of the pier. She fell to the rock pool below.

The tide was out. She landed on her backside. Before the big dive Jo was

telling her friend the (utterly mythical) story that St Andrews students who

fell from the pier and died were awarded a posthumous first class honours

degree.

(Day 6, Wednesday, August 27, 2008) Please don't think this will become a

daily update. This is brief news and no more. The surgery, scheduled for

tomorrow (Thursday 28th) has been delayed until Saturday or Monday,

owing to unresolved abdominal swelling caused by the impact after the fall.

Jo looked a bit worse today than yesterday. I suspect that one of the pieces of

scaffolding on Jo's abdomen is heading to infection, and hospital acquired

infection is just a ferocious curse, as you would know. Her belly is quite

distended right now, and the surgery is to involve a cut from left hip to right

hip around the stomach, and the dangers which this manner of surgery

brings involve blood vessels and nerve endings (Jo's medical student

daughter Kat tells me now that the dangers are to the iliac and femoral

arteries, and the abdominal aorta, and major nerve damage risks).

The pain management has improved dramatically with the realisation by the

"pain team" (you couldn’t make this stuff up) that morphine is no good for

nerve pain, that the sacrum (the bit of bone fusing the spine to the pelvis) is a

conduit of nerve impulses, and that sacrum damage can cause shooting pains,

of precisely the kind Jo’s has been suffering. The solution is something called

a nerve blocker, and no I don’t know what that is either. It has been a great

relief for Jo to understand why her pain has not been responding to the loads

of morphine she has been taking, and to know that there is an end in sight

for this pain at least.

(Day 8, Friday, August 29, 2008) Jo has had a bad couple of nights and is in

rather lower spirits than before. The nights seem rather bad, mornings less

so. For about 36 hours, until about midnight last night, she was off the "nil by

mouth" list. She managed a little food. She is for now back on the list. The

gastric problems have not cleared up, so that the surgery has been postponed

to next Thursday at the earliest.

The pain management is decreasingly successful, the morphine and its oral

variants cause nausea, and not enough pain relief in my judgement. Kat and

I will visit Ward 17 again today at the usual time. In addition, we will hang

around today for the 6-8 visiting session, just to see experimentally whether

the result is positive or negative for Jo's subsequent night alone.

(Day 10, Sunday, August 31, 2008) Jo is on track for surgery on Thursday. A

general surgeon expressed his preparedness to bet a month's salary on Friday

that Jo's digestive problems would be resolved by the end of the weekend.

Unless there is a late run, it's looking like a bad bet.

Jo's pain management suddenly got much better today. The last two nights

have been bad. She has six pain locations; two are irrelevant (her throat from

the nil by mouth plus 24 hour a day fan for the heating up caused by the

morphine, and the broken elbow) and the rest are not. Of the remaining four

pain locations, three were being taken care of perfectly well with the

morphine, though (as I think I indicated in an earlier instalment) there were

problems on Monday through Wednesday, partly caused by Jo trying to tough

it out, and partly caused by overworked Ward staff.

But the final pain location, shooting pains down the left (and recall

unbroken) leg, have been scaring Jo lots because they have not responded to

the painkillers.

This morning the captain of the pain team (well there is a pain team, but

insofar as I know it has no captain, I made that bit up) visited, and diagnosed

the problem. The problem is that morphine does not affect nerve pain. And

nerve pain is a common consequence of sacrum damage.

Tomorrow morning a nerve blocker will be introduced, and that should cure

the problem. Jo is doubly relieved, relieved that there is a reason for the pain

she has been experiencing, and relieved that it should end tomorrow.

There's not much else to report really. I could detail the progress of the

digestive problems, but I’m eating. The best I can say is that the jelly that

she nibbled today that Kat got for her (Jo is off the nil by mouth list again)

was wonderful.

The best we can do for her now I think, supernatural intervention and such

things apart, is the small thrills and surprises that cut through the pain and

the boredom. Tom sent three photos of Jo’s granddaughter; I took them in

today. The smile they evoked was very broad. I have organised an i-pod, with

heaps of Jo's favourite music, to be delivered, at Jo's request, after the

surgery. The updates on the progress of the Chelsea - Tottenham game today

were marvellously fine. And I know that the phone calls that Jo has made

and received have really cheered her.

With regard to the latter, it is worth saying something out loud even though

it might have been obvious to you. Jo's throat hurts because of the constant

rush of cold air from the fan. And sometimes that pain and the painkillers

make talking a trial for her. Do make sure that when you ring her you keep

up at least half of the conversation, and that you are sensitive to her

tiredness. That doesn't mean don't call! It just means listen carefully.

(Day 12, Tuesday, Sep 2, 2008) There have been many developments, few

welcome.

The digestive problems are easing but not over. Jo had a little fish this

evening, a little jelly and some tomatoes today (brilliant Kat!). The Thursday

timetable has been confirmed. The surgery is likely to start around 9 am and

to finish around 7 pm. Thereafter Jo will go to Ward 9 for one or several days

of high-intensity post-operative nursing. Jo has told me I may as well stay

away that day. She is learning that the patient is often not in control. This

will be a further example.

However, when control is possible it should be in the patient's hands. So the

morphine pain gun has been restored. Jo herself gets to control the morphine.

This has been excellent. It means that when Jo knows something quite

painful is going to happen (being taken for an x-ray or other scan or using the

bedpan for example) she can dose herself up.

Jo has a urinary tract infection, indeed it was self-diagnosed last Friday. She

is on antibiotics, which are rather complicating the recovery from the

digestive problems.

It was decided that the pain treatment for the nerve problems in the left leg

must wait until after the surgery. Jo has accepted that stoically, and at least

now knows the cause of the problem.

Perhaps the worst news is that Jo has had a blood clot in her lung. Blood

clots are apparently common in major traumas like this. The blood clot that

she had has dissolved. Today and tomorrow she is being given heavy blood-

thinning to minimise the chance of a recurrence.

In addition, tomorrow (Wednesday) under local anaesthetic, a filter will be

installed, in Jo's neck. The filter is intended to catch any further clots before

they reach the brain. The filter will remain in place for some time

postoperatively, and there will be Warfarin treatment after the operation.

The risk which this filter entails is that occasionally it proves impossible to

safely remove the filter. If that happens, it means the filter must remain in

situ for Jo's whole life, and she must take warfarin for the whole of her life. I

do not know the odds of this happening. Jo is aware of all these risks.

I finally got to observe the orthopaedic surgeon. There is something here

reminiscent of Major Major in Catch-22: you can only see the surgeons when

they are not there, or more accurately you only see surgeons when visitors

are not there. So I stayed beyond visiting hours, pretended to be part of the

furniture, and saw and listened to him. He is smart, calm, and has very

powerful hands. I can see why Jo has such faith in him.

The clot problem has made an already risky procedure even riskier. Jo is well

aware of that. She is trying to rest for Thursday, she is doing her best to be

calm and positive. Before I left the hospital tonight, she said to me "I want to

live", and there was not a skerrick of self-pity or fear. She really means it.

Surgery

(Day 14, Thursday, Sep 4, 2008) Jo went off to theatre (cue jokes from acting

and English Lit types) at 10.30 this morning, accompanied by the best nurse

on the Ward, perhaps world. The surgery is of about 10 hours duration, and it

will be several hours after that that she regains consciousness.

Immediately after surgery she will be in "theatre recovery", then she will be

moved to another unit. She may be moved to the High Dependency Unit

(HDU)(Ward 9). She may be moved to the Intensive Care Unit. The surgeon

(Mr Alipour) and his team were careful to tell Jo that if it were the Intensive

Care Unit no unfavourable inferences about her condition should be drawn -

it would just be a consequence of a shortage of bed spaces in HDU. The

visiting hours in Ward 9 are 3-8pm.

When she has recovered sufficiently, Jo will return to the same (thankfully

single occupancy) room in Ward 17. The visiting hours there are 2.30-4.30

and 6-8.

Can I make several gentle suggestions: First, can you all allow me and Kat to

monitor and report on Jo's condition, to avoid her various locations being

swamped with phone calls. We will report promptly and frequently in the

next 72 hours.

Second, can I suggest that no-one visit tomorrow (Friday), whether she is in

HDU or ICU. After such arduous surgery she won't be in a position to

entertain visitors.

Third, Jo gave me her mobile phone until she is back in Ward 17. If you want

to ask me anything or for me to pass along any message, you can do it by

return email or to Jo's mobile phone or to Jo's cat's flat.

Finally, as I should have mentioned previously, flowers are not permitted on

any of these Wards (Ward 17, HDU and ICU). If you want to give Jo a

reminder of your thoughts for her, you'll need to find a more imaginative way.

I'll close with just four further things about Jo's night and morning before the

surgery. First, she got to eat just a little food the evening before, which has

not happened frequently in the preceding ten days, and was welcome for that

reason. The food was mostly unlovely, oversalted and oversugared frankly,

but was washed down with a pint of whole blood, some morphine and some

diazepam. Second, she got some live entertainment, Bruce Springsteen and

the Seeger Sessions band, not really live, for they are an 18 piece band, but

on her hospital TV by DVD, which was near as good. It seemed to have a

welcome calming quieting influence on the ancient loud broken-hipped

gentleman in the next room. Jo liked it too. Third, one of the excellent nurses

encouraged her to embrace what was to happen today by observing that the

surgery would mean that Jo was no longer treading water. The unintended

irony was not lost on Jo, given the circumstances in which this all occurred.

Jo laughed uproariously. Finally, Jo received a fabulous card several days ago

(one of many lovely cards she has received), from a person named David

Jones. He is the Secretary of The Sir Robert Jones dining club. For those few

of you who do not know, Jo is currently engaged in writing a biography of Sir

Robert Jones, the father of orthopaedic surgery. The card is large, and bears

a photograph of Sir Robert Jones on the front. She had the card pinned above

and behind her bed. When the orthopaedic surgical team assembled this

morning, she gestured backwards with the thumb of her good hand, and

remarked simply, "remember, he's watching".

(Day 14, Thursday, Sep 4, 2008) The operation was a success, though as with

all surgery and all orthopaedics there are serious post-operative risks. Jo is

recovering in the Intensive Care Unit. Further details will follow, in about 18

hours.

(Day 15, Friday, Sep 5, 2008) Jo continues to recuperate in the Intensive

Care Unit, where she will remain for much of the weekend. The pain is very

bad, and the resulting heavy morphine use has caused some breathing

difficulties overnight. This morning an epidural was installed. I had several

pain management suggestions myself, the only one of which gained any

traction with the professionals was the migration of Lola the stuffed panda

bear from Ward 17 to ICU.

The epidural has been installed. It hurt like hell, not the spinal puncturing

but manouvering Jo into place. But its impact has been dramatic. It turns out

she has no memory of me being there this morning (before the epidural

installation), though she did give me (or at least my t-shirt) a big old smile

then, which fooled me. She has a tube in her mouth, which means she can't

talk, and the tube itself is quite uncomfortable. From the waist up the bed is

permanently at an angle of about 35 degrees from the horizontal, to allow her

to breathe. She really had serious breathing problems last night.

The nursing is intense (if you've not seen an ICU before, each bed has a

permanently stationed nurse, and there is at least one doctor in the room)

and of high quality. The room is well designed so that the six patients cannot

see each other. I saw all of them, and it was sometimes pretty grim viewing.

If they entered all of 'em into the intensive care events at the Paralympics

starting Sunday, my money would be on Jo for the gold.

Jo cannot talk but she can write. And the much better mix of drugs which the

epidural permits means that her writing looks normal now, not like that of a

six year old, though her spelling is idiosyncratic compared to the usual.

The throat tube is likely to be removed tomorrow, and a return to Ward 17 on

Sunday seems likely. She is in good spirits overall, given the long and

difficult surgery, and looks so much better than she did this morning.

(Day 16, Saturday, Sep 6, 2008) Overall a really very good day. Jo still has an

annoying gastro-nasal tube and a nasal canula, but is so much brighter now

that the tube down her throat (upside down scuba equipment as I call it) has

been removed (Jo will never watch Scene 10 of "The Matrix" in the same way

again).

One of the three wounds (behind the hip on the worse side, the left side from

Jo's point of view) has been leaking, and the surgical team came to inspect

the site. Afterwards, at Jo's request (because she was very groggy from the

epidural top-up they gave her to cope with the examination) they sat down

(yes, actually sat down!) to explain the situation to me, and to let me ask

questions.

The two continuing main problems she has (the leak and low oxygen levels in

her blood) are both related to the IV blood-thinning agent that they have

been administering, to avoid further pulmonary embolisms (blood clots) (or is

that embola, embolu? I don't know). This is a price worth paying. It is

prudent.

Almost all of the rest is really good news. In two days they will be shifting her

to an oral blood-thinning agent. This will reduce the pair of problems. Best of

all, the wound is clean, that is uninfected. The surgical view is that her

progress is good.

Now a couple of slightly less good but relatively minor matters. First, Jo was

a little bit jaundiced today. The cause is her liver working to break down the

blood clot she suffered earlier. Remember that she has a small filter installed

in her neck, so the clot can't make it to her brain. Though the surgical view is

that Jo will be ready very soon to return to the general orthopaedic Ward

(Ward 17) that is not going to happen because (as the surgeons pointed out,

somewhat surprisingly) few orthopaedic nurses have the training to manage

an epidural. So Jo will either remain on ICU or be shifted to HDU (the high-

dependency unit). This might occupy the next 3 or 4 days, but the timing is

fluid.

From my point of view this is just outstanding news. The intensity and

standard of nursing in ICU is great, as is their careful insistence on hygiene

standards. Added to all this, Jo's main daytime one-to-one nurse is just

outstanding. She is so skilful, responsive, careful. She is a Zimbabwean

named Lavender. I entertained her by inventing three sisters for her, two

older sisters (rose and violet), and an unfortunate much put upon younger

one (chrysanthemum).

Two last and more serious things. First, I somewhat fascistically insisted on

no visitors for Jo until she gets back to Ward 17. But Jo is in control of the

few things she is in control of, and this has to be one of them. So I asked her

whether she would like visitors. Not yet was her decision. I'll let you know

when that changes. In the meantime, I pass along every message that comes

to this e-mail address, and please feel free to call me at the flat of Isla (the

wonder cat). When I'm not at the hospital, I am here. Isla doesn't take calls.

Second, the plethora of electronic equipment around her bed means that Jo's

mobile doesn't work in ICU or HDU, and in any case the phone has some

power problems for now. So the landline and the e-mail are your only

communication methods for now.

(Day 17, Sunday, Sep 7, 2008) In place of the usual, for you must be as tired

as I am sometimes of my voice rather than Jo's, I offer just this little thing.

Lavender had a deserved day off, and Jo's one-to-one nurse was Emma, the

quite young Emma Dickson of Dundee. For reasons which are unclear to me,

Jo and she were constructing a list of good things that had happened today

when I arrived. I asked Emma to Jot them down for me. This is the list, with

my own brief explications in brackets. This is what dear Emma wrote:-

"1. less jaundiced

2. pain more controlled

3. ECG normal

4. Dr Mellor (the ICU supremo) sees improvement

5. 02 percentage (being pumped into Jo's nostrils through the nasal canula)

reduced

6. bowels/gut working

7. started feeding (though an IV tube, and Emma did a test for refeeding

syndrome. You don't need to know what that is, and I don't really know

either, but Jo doesn’t have it. She digests!)

8. wound looking good (still no sign of infection)

9. well enough to leave ICU (for HDU) if bed needed"

More tomorrow. This is looking better.

Recovery

(Day 18, Monday, Sep 8, 2008) Today was Jo's best day yet. It is no

exaggeration to describe her continuing recovery as remarkable and amazing.

The surgeons, and especially the intensive care staff, and Jo too, have all

done better than splendidly.

The jaundice has gone. The gastro-nasal tube has been removed. The

epidural has been removed. The course of IV antibiotics for the UTI is

complete. The wounds remain uninfected. She ate a little food.

Today Jo left intensive care and returned to the general orthopaedic ward,

Ward 17. She will have her mobile phone from tomorrow morning. Jo wants

to concentrate on resting and on adjusting to her new pain management

regime. She is determined to launch herself single-mindedly into her physical

rehabilitation as soon as possible. Today she declared her intention to walk

(rather than roll) out of the hospital, when ready. For all those reasons, she

would be grateful if she could avoid visitors for just the next few days. I will

alert you when her decision changes.

(Day 22, Friday, Sep 12, 2008) There are seven stages to Jo's recovery: to sit

up in bed (at a little less than a 90 degree angle between legs and torso); to

sit on the side of the bed legs dangling free; to sit in a chair; to stand with a

frame; to walk with the frame; to walk; to run.

Yesterday she failed the first. Today she achieved the first and second. It

hurt a lot, but Jo was quite fearless. She had the help of two physios plus me,

but the endeavour was all hers. It is outstanding and seriously determined

progress. The surgeon's view is that, depending on an assessment of

conditions at her flat (the stairs are the main problem), she could be released

in as little as two weeks, though three is more realistic.

An anticipated six months of Warfarin treatment started yesterday. The last

of the lines, tubes and canulae into her (a central line to her throat) is to be

removed very early tomorrow morning. It is likely that the filter in her neck

will be removed early next week, depending on the progress of the Warfarin

treatment and an assessment of the condition of the filter.

Hospital visits are now welcome, as have been all the cards she has been

receiving. Just to remind, she is in Ward 17 of Ninewells Hospital in Dundee,

visiting hours are 2-30 to 4-30 and 6 to 8. If you are able, a phone call a little

in advance to Jo would be wise.

(Day 30, Saturday, Sep 20, 2008) Well, it's been a quiet week in Ninewells

hospital. There was, by and large, a lot of music in the air.

The patient persists determinedly. One of the surgical wounds remains

infected with e-coli, and after the failure of the 19th century strategy

(bombardment with iodine) to eliminate it, we've moved to the 20th century

strategy, a cocktail of generic antibiotics that rhyme with penicillin. These

are designed to match perfectly with her blood though, as it turned out, the

match with her stomach was less exact. It's enough to say that Jo is still

eating, though with little relish, and that anti-emetic treatment is being

applied. Jo has an incipient bedsore, but the site has been packed and treated

well.

George, who I may have mentioned before, is Jo's next door neighbour, an old

man with a broken hip and Alzheimers, a former English teacher like Jo, who

spends a lot of his time distressed because he doesn't really understand

where he is. George had the loveliest night of his recent forgotten times on

Thursday. There would be an easy way to make George's life better, but no-

one with any initiative or authority seems to have noticed it yet. In the

patient rooms at Ninewells hospital, the pinboards are behind the bed. This

is poor design. Who is in the room most? The patient. For whom should we

position the pinboard? Ditto. In Jo's case it could be selected things of

remarkable beauty, a photo of a grandchild, a reproduction of a painting, and

so on. In George's case it could be a big-lettered sign, "You are in Ninewells

hospital, be calm", which he forgets to do. George also forgets the existence

and function of the little handset for calling for nursing assistance, so he

hollers "help", except it is more like "heeeeeeeeeeeeeeeeeeeeeeeeeeeelp". He

hollers in a loud clear voice. On occasion, George forgets that his hip is

broken, and steps up from his chair. The results are always calamitous.

George is stuck in a rut, in more ways than you might imagine. So he sings

out his "help" when thirsty or hungry or baffled or other things. He did that

the other day, " heeeeeeeeeeeeeeeeeeeeeeeeeeelp", and he meant he wanted a

cup of tea, which he got. But then with the same single note pitch and volume

and timbre, after a brief delay, he essayed

"sssssssssuuuuuuuuuuuuuuuuuuuuuuuuuuuggggggggaaaaaaaaaaaaar".

George likes his tea sweet. We should do something about that pinboard.

He also likes Scottish country dance music, and is a harmonicist of quality.

So on Thursday his family bought in some dance music and his harmonica,

and he played with the music, and then on his own, a capella, and then the

whole ward, nurses and patients and administrators and medics and visitors,

applauded. It was so lovely. George was George again, briefly.

Jo has her own musical strategies. When they roll her in the bed to tend her,

she sings medleys from popular music. "All things bright and beautiful", all

27 verses, though the commonplace opinion is that the official version has

fewer. "mama mia, here I go again", when it hurts a little more. And in

moments of really intense pain, "Oklahoma", with the first letter held long so

that it becomes "ooooooooooooooooooooooooooooooooooooklohoma".

You might think this lacks dignity, but it is in fact a cunning strategy, to

share the indignity around, for Jo insists that the tending nurses sing along

with her. And if you have ever been to a karaoke night, you will harbour true

suspicions of the results. Jo might crave a whole lot of dignity right now, but

at least she can hold a note.

When the physio happens, as it does five days a week without fail (but not at

weekends, the medical logic of which eludes me), she becomes a chorister,

purer in her musical choices. So, and this is a genuine novelty, when the

physio entails pain, she sings a single note, and the pitch and volume are

related to the intensity of the pain, systematically. Yesterday, in one physio

session, she stood up, and then sat down, and then said "never ever give in"

and "never ever give up", and then said "Phar Lap" (whatever that means),

and stood up again. Twice in one session! It was superb, and all accompanied

by no shouting nor cursing but only by singing.

The aim next week is to sit in a chair. It doesn't strain the imagination,

particularly the female imagination, to understand that this will improve Jo's

life immensely. The aim is to sit in the chair on Wednesday. Every

physiotherapist at Ninewells hospital is named Laura, or so it seems, and the

initial impression left by the new Laura (after last week's wee Laura) was

blunt boisterousness, but we mistook things entirely, and she is just fine.

Every session of physio is defter than the previous, manouvres achieved more

swiftly, and accompanied by singing of lower pitch and volume. Jo is turning

from soprano to alto, which is just fine.

If I haven't thanked you individually, and even if I have, thanks for all the

cards and books and treats and surprises and boxes of hedonism. They all

make life easier and better for Jo.

(Day 31, Mon, Sep 22, 2008) A day of progress, risks, worries.

The progress is spectacular. 48 hours ahead of schedule, Jo sat in a chair

today. It is the first time in a month she has sat in a chair. She sat in the

chair for 75 minutes. And the pain of it is not just sitting there, it is getting

there. It sounds like a ditchdigger's sarcastic jibe at an office clerk, but this

was seriously hard work. It was made more so because Jo engages in

anticipatory tension, from mistrust and a desire for control, so that when the

time comes for real effort she is sometimes already half-exhausted. We'll be

working on that.

The current risks can be recounted without labouring them: the risk that the

e-coli infection persists and that the surgeon has to "go in again" (that's a

direct quote from the surgeon) to check whether his titanium work is affected,

infected; the risk that the filter in her jugular, designed to stop blood clots

getting to her brain, cannot be safely removed, which would imply lifetime

Warfarin use and the attendant risks of osteoporosis and purple toe

syndrome. That procedure happens tomorrow.

The worries are generated indirectly by Jo's move, on Sunday, from a private

room to a six bed ward. Of course, you will understand the costs of this to Jo

in the loss of privacy and dignity and rest. Others' groans and visitors gall.

The nursing staff gave Jo an explanation for this move, and it was that a

male admission had to be made, and that this necessitated her being moved

to a six-bed female ward. The real worry is that, to an unusual degree, Jo is

perceptive, desires control, and is prone to mistrust. If the clinicians mess

with that trust it is no hypothetical ethical curiosum, it goes straight to the

effectiveness of her medical care. Jo's own hypothesis is that this was a

paternalistic decision that "company" will improve her recovery, that

"isolation" and "solitude" are inimical to her good health. So many reading

this are writers, or know Jo well, or both, and will know this to be the veriest

nonsense, in Jo's case. Now the evidence is not yet clear, but 36 hours later,

Jo's single room remains empty, and Jo knows it. The man destined for the

room may have died, may be in intensive care, might have been abducted by

aliens or subject to gender reassignment. But I think Jo doubts all those

explanations. Time will tell. My suspicion is that he is not coming, nor was he

ever.

As I Ieft this evening I gave Jo a hug of comfort and support. A passing

nurse, in an exercise of what passes for wit in Dundee, said, "get a room".

"We had one", Jo whispered to me.

A few of you have been kind enough to inquire about me. I met a gentle man,

who visited Jo today. We used to work together, he and I, and he knows my

love of the laconic. "How are you?", he asked. "Thirty days in, maybe 40 to

come, I've been worse", I said, and he understood my calm tone.

More have inquired about Lola, Jo's constant companion, a stuffed toy panda

bear. Jo gets to choose from the menu for the next day, and there is a too

small box on the form for comments to the kitchen. In substitution for what

might be the usual pattern of dog's abuse, Jo has provided panda pleas over a

series of days, pleas for proper bamboo shoots, pleas that Lola not be left to

live on the meagre offcuts from the black bamboo market, pleas that anorexia

is impending. So far this has produced no bamboo, but I suspect that

Ninewells kitchen is unaccountably gigglesome or baffled.

I'll let you know how the filter removal goes.

(Day 33, Tuesday, Sep 23, 2008, AM) This communication just in from the

Ninewells kitchen: "sorry, we've run out of bamboo, you'll have to feed Lola

something else". Pandas are known to eat yams when there is no bamboo

available. Jo shall have to ask for some.

(Day 33, Tuesday, Sep 23, 2008, PM) "This saved my life", Jo said, and she

handed me the titanium filter they had removed from her jugular. As with

the patient hoist, this piece of medical technology fairly defies my powers of

description. Jo was told that it cost six hundred pounds, but that is so

irrelevant it scarcely bears mention. I had imagined a narrow tubular

jugular-width chromed pipe, topped by a filter, as seen in the making of a

good cup of tea, but it is nothing of the sort.

The closest description (I am looking online for a picture) I can muster is this

one. As a child, a great treat was fish and chips on a Friday. And the bloke

(for he always was a he) would retrieve pickled onions from a large jar with a

pencil, from which protruded, on the push of a button, something like the

slender legs of spiders, but metallic. Eliminate the pencil part of the design

and you are on the right track. And when removed from Jo (as it has been, so

that, except for the e-coli, we really are on the home straight of treatment,

and heading towards only recovery and rehabilitation and release) it revealed

a clot. The little spider did its job. Six hundred pounds utterly brilliantly

spent.

All that remains is to tell you that, when deprived of bamboo, pandas are

partial to yams. So Jo's little message to the Ninewells kitchen tonight read

"Absent bamboo, pandas prefer yams. A plate of Szechuan Yams would be

just lovely".

(Day 36, Friday, Sep 26, 2008, AM) Again, the recent experience has been

mixed and confusing. Jo is sometimes teary and depressed, though not to an

extent requiring medication.

It is difficult to disentangle the effects of the duration of her hospitalisation

(36 days), the likely further duration (no idea frankly, somewhere between 14

and 50 days), the recent paternalistic decision to move her to an open bay (a

corridor, in Jo's own words), a range of bedsores and similar niggles, and the

pain medication. The painkillers also cause sporadic auditory and visual

hallucinations. Her treatment, physiotherapy and rehabilitation go well

enough. The antiblood-clot filter in Jo's jugular has been removed,

successfully. Her upper body strength has recovered, owing primarily to

determined eating and exercising. She can now move herself up the bed, such

a sharp improvement on being heaved along by two or more nurses, and she

can be rolled onto her side by one or two expert nurses, when it took six in

intensive care and hurt like hell. Yesterday she sat up for five and a half

hours. Jo's leg strength and flexibility remains quite limited, though is better

than previously, and her legs and feet are swollen and painful ("elephantine"

is Jo's own mournful term).

Events which might normally be trivial and unremarkable assume a growing

significance for Jo. She had her first shower; she sang "singing in the rain".

By a brilliant coincidence that could only have issued from an accomplished

novelist, she received a little package of bathing accessories that very

morning. She has been visited a few times this week, and the visits have been

a delight. Finally, she is getting some joy from an imagined plot involving St

Andrews pier, and industrial quantities of coca-cola and mentos mints, but

this too may well be an hallucination.

I am unhappy with the flow of information to me. My best information comes

from cleaners and nursing assistants, my own (admittedly inexpert) reading

of Jo's file (to which I presumptuously help myself), and indirectly via Jo, who

is sometimes a bit confused by the drugs. I gather further information from

being at the bedside when treatments occur, but that is now reduced to four

hours a day, from a previous six or eight, owing to the move to the open ward.

The main rehab aim of the coming days is to get from bed to stand at a gutter

walking frame, without using a patient hoist. In addition, today the seeping

and e-coli infected surgical wound is to be treated with a vacuum or suction

bandage. If you do not know what this is, you are in some good company, for

neither do I nor any of the nurses, so installation will be accompanied by a

training session for the nurses, this morning at 11. I wasn't invited. Finally,

the catheter will be removed soon.

(Day 36, Friday, Sep 26, 2008, PM) Two quickies. First, this morning, Jo

made it, on her own, without machines or nurses, from the side of the bed to a

standing (on one leg, like a bent flamingo, in her words) position at the gutter

walking frame. Four times!! Jo is well on her training schedule for the

London Olympics (1400 days to go today1) and can be expected to be a dual

medallist in the hopscotch and in the hoppo-bumpo.2

Second, Jo thinks she may have a fracture somewhere in the lower left leg.

The surgeon agrees. X-rays are being taken today.

(Day 37, Saturday, Sep 27, 2008) Slightly worrying news this morning, Jo is

convinced that the long surgical wound across her abdomen is infected. Laura

the lovely nurse (the one who accompanied her from Ward 17 to surgery so

long ago) (and yes, I know, even without my exaggeration, we have a lot of

Lauras going on here - wee and boisterous Lauras, both physios, and lovely

Laura, a superb nurse) thinks so too, and they are swabbing the area as I

write. I'll let you know of the progress.

For reasons which are unclear to me and Jo the vacuum bandage was not

installed yesterday.

The x-rays of the lower left leg were taken yesterday, Jo hasn't any official

news yet, but the unofficial hints are that it isn't a fracture. I'll let you know.

She will find out today I suspect.

Jo has decided, following advice from one of the recipients of all this, that a

chat to a clinical psychologist would be a good idea. It might carry some

1 http://www.london2012.com. 2 http://hoppobumpo.blogspot.com.

benefits, it can't do any harm, and Jo expects to be able to enlist an ally in

getting the hell out of the geriatric corridor (Jo has at least 20 years on

everyone who has been in the open Ward since she got there; no-one in this or

any other open part of Ward 17 has been in the hospital as long as Jo; none

will be in there as long as Jo has remaining in hospital).

In totally irrelevant news, a cackhanded phlebotomist spilled blood on Lola

this morning. Lovely Laura cleaned Lola. You will recall that Jo was

unsuccessful in soliciting bamboo shoots and a nice plate of Szechuan yams

from the Ninewells kitchen. Yesterday, Jo explained the panda bear's

unusual hunger by communicating to the kitchen that Lola is great with cub,

that the panda has a bun in the oven, which Jo simulated by tucking a white

roll into the waistband of the bear's little gauze bandage trousers. Today, she

plans to tell the kitchen that Lola is delivered of child, that panda and cub

are doing fine, and to ask the kitchen whether there is any chance they have

any yak's milk in stock.

(Day 38, Sunday, Sep 28, 2008) It might be my tiredness, which I bring home

to the cat rather than in to the hospital room, but my instinct is that we are

at a little bit of a cusp; that is, it might go either direction in the next several

days. Briefly, these are the factors:-

(1) Jo was tired today, at least in part from her emotional reaction to the

move back to a single room, and the deal which they made her to get there, to

have a shower every day. She had a shower, she sang in the shower, loud, the

whole ward applauded. As you recall from the tale of George (it is his old

room), Room 1 has great acoustics

(2) Yesterday her left leg and foot in particular hurt like hell, today both legs

were so swollen. I just don’t understand why, and it seems that (unofficially

still) it’s not a hairline fracture or anything. I saw what was in her eyes, it

looks like they have transplanted her mother's legs onto her.

(3) The big cross-abdomen surgical wound is the new suspected infection site,

and the pathology results won’t be back until tomorrow at the earliest,

probably Tuesday.

(4) A complicating factor I have not mentioned is the TENS machine.3 She

has used it twice, both times perhaps overdoing it, and both times it has

produced more pain, not less as is the purpose.

3 http://en.wikipedia.org/wiki/Transcutaneous_Electrical_Nerve_Stimulator

(5) Her gums hurt. Also, I think her teeth are discolouring a bit. Since giving

up cigarettes 38 days ago they went whiter. Now they are going in the other

direction, sort of greyer. I wonder if that is an antibiotic side-effect.

I'll leave it there. I have no neat solution or conclusion.

(Day 38, Sunday, Sep 28, 2008) Jo is being moved early this afternoon to a

single side room in Ward 17. She rang just then, quite quite quite chuffed.

(Day 39, Monday, Sep 29, 2008) She walks. I said Jo was teary and depressed

from time to time, and she is, with good reason; she is also teary and

triumphant on occasion, as she was just now on the phone. She got from her

bed to her chair on her own, and she is now in a sizeable single side room (no

more corridor, no more Macbeth witches, the nurses saw finally what an

impediment to recovery that was) so the distance was substantial.

She stood up at the gutter frame, unaided, and then she shimmied (her own

word) across the room (using the slippers that Kat bought in to the hospital

36 days ago, and the inspiration of someone who asked me recently, "how old

is she, you know the older the patient the slower the recovery ..."), and some

mantras about a cat and a horse, and a fixed idea that no matter how much it

hurts she is going to get out of the hospital as soon as she can.

And she made it to the chair, and sat down alone in the chair, nearly fainting

for forgetting to breathe in the midst of the indomitable effort, and then said

six words. Two were to the physio, boisterous Laura, and the two words were

"thank you". Then she said another four words. Three of them were "I made

it". And she did it all without taking extra pain killers in preparation. It is

awesome, awe-inspiring.

She is now having a wee celebratory party, consisting of a jug of iced water

and a rich tea biscuit.

If you have a mobile phone it might be a grand idea to send a little note of

congratulations, admiration, approbation.

Setbacks

(Day 42, Thursday, Oct 2, 2008, AM) MRSA in the largest surgical wound.

(Day 42, Thursday, Oct 2, 2008, PM) Just to confirm the previous, Jo has

been diagnosed with methicillin resistant staphylococcus aurelia (MRSA),

which is an infection which is resistant to traditional antibiotic treatments.

You may have heard this described as a "superbug".

This is a very serious infection. I could recite mortality statistics, but to be

frank they are of little use for a specific patient. Jo lives, or not; this is not

probabilistic. Mortality rates are lower for younger patients, and lower for

healthier patients, and I account Jo to be at the desirable ends of both these

spectra. It might seem that she is not at the good end of the "health"

spectrum, given the trauma she has suffered, but she is remarkably healthy

(and here I am reporting the remarks of her nursing, surgical and

physiotheraphy staff) compared to four weeks ago. The prescribed treatment,

which is standard, is vancomycin and rifampicin. The former is administered

intravenously, and this had already begun as I write (but tomorrow a more

effective IV method will be pursued, a PICC line). The latter is administered

orally.

The particular risk here (other than the significant side-effects and risks

associated with vancomycin and rifampicin themselves, more of which below)

is that the bones or organs will become infected with MRSA, or that the

infection will spread to other surgical wounds and bed sores. Jo is suffering

from several of the latter. The previous treatment for these bed sores was to

leave them open, to allow them to "breathe". Now they have been fully

dressed to protect against cross-infection. The treatment for the previous e-

coli infection has been successful, and the antibiotics for that have been

discontinued. This minimises the chances of interaction effects, more of which

below.

More rigorous hand-washing products and procedures have been introduced

for Jo's room. Jo and I are meeting with the infection management team

tomorrow, and if there are any broader implications, particularly regarding

visits, I will write again. The serious risk which rifampicin presents is

hepatotoxicity, that is impairment of liver function. The main serious risk

which vancomycin presents is nephrotoxicity, that is impairment of kidney

function.

There are many interaction risks, that is risks that the effectiveness of the

treatment will be impaired by its interaction with the other drugs which Jo is

taking. In addition, there is the worrying possibility that this might be a

vancomycin-resistant infection. It was once the case that vancomycin was the

drug of last resort for infections of this nature, but that is no longer the case.

The other side-effects of this course of treatment are associated with the fact

that these are severe antibiotics.

For rifampicin, and I am writing from memory here, the side effects can

include severe nausea, jaundice and fevers, which is particularly worrying in

Jo's case given that she is already suffering hallucinations from the diazepam

and other treatments.

For vancomycin, the main side-effects include nausea, chills and weakness.

The latter is worrying, and might indicate the need to suspend or curtail

physiotherapy.4

(Day 43, Friday, Oct 3, 2008) (I was a little tired last night when I sent the

previous. I do want to avoid confusion, and I hope the four things further I

have to say here help that)

First, I mentioned that the combined vancomycin - rifampicin treatment

interacts with other drugs. In particular, it interacts with the Warfarin.

Warfarin is a blood thinning agent, it is used to avoid any further blood clots.

I spoke to the surgeon about this this morning. He said, and I quote

"everything interacts with Warfarin". This might well be the closest we will

come to an orthopaedic surgeon's equivalent of a pathology joke. But there is

no particular cause for concern. Every day a blood sample is taken from Jo (so

her arms now are rather well bruised, and it requires real skill to get a good

blood sample) and the blood is tested for its coagulation or clotting (using a

measure called the INR, the International Normalized Ratio). If the INR is

up the Warfarin is reduced, and vice versa.

Second, the real hope is that this is just a "small" MRSA outbreak in the

wound itself (the literature calls such infections non-serious, to contrast it

with, for instance, pneumonia caused by MRSA), that it has not spread

beyond that site, and that the treatment will destroy it quickly.

Third, I mentioned that vancomycin used to be the only drug available to

treat this condition, though now the evidence is overwhelming that treatment

is much more effective when it is combined with rifampicin, as it is with Jo.

But about six years ago a new drug was discovered, with several names, as

usual (linezolid or zyvox, which sounds like a Douglas Adams character), so

that if this course of treatment does not work or if the infection proves to be

vancomycin-resistant, there is a further well-proven option.

Finally, I thought I should strike a note of anticipatory reassurance. The

infection was first noticed (by lovely Laura, the senior charge nurse) last

4 In case you are wondering how in heaven's name an economist, if you care to define me as

such, came to know these things about MRSA, a short note of explanation is in order. 22

months ago, my father had a heart attack. My mother, who was present, held him alive with

CPR (and was awarded a medal by the Victorian Parliament as a community hero for her

initiative and valour, making a private hero a public one). Then my father had a pacemaker

popped in, but contracted MRSA, then pneumonia. He survived both, and indeed he is the

inspiration for Jo's determination to walk, not roll, out of hospital, for this is precisely what

he did. I spent dozens of hours studying all these things way back then. He was treated with

rifampicin and vancomycin. He survives. He is 75 years old.

Sunday. She took a swab. Now you might be thinking to yourself, why did it

take until Thursday for the diagnosis? In short, that's how long pharmacology

takes. The swab has to be cultured in the laboratory, then it has to be

studied, to figure out what it is and what drug combination will destroy it.

The delay in this case is typical, it is not inordinate, it does not indicate

negligence or inattention. That's how long pathology takes.

(Day 44, Saturday, Oct 4, 2008) Jo got a wheelchair, which she used. It is a

black wheelchair, and it is funky and cool, or whatever the current words for

tremendous might be. For the very first time in all this time, she got to wheel

free from Ward 17, and she chose the lovely staff canteen at Ninewells as her

first of many destinations. She had sunshine on her face, and trees in view,

and a gorgeous ribena. It was so splendid, and yet when offered a quick

escape on her way back to the Ward, a bolt through the door, she demurred,

and insisted she would go back to face all that remains.

Jo has a colony of MRSA in the largest of her three surgical wounds. It is not

clear whether the infection has spread to her bones or her titanium or

elsewhere, which could be very serious. There is a good reason to believe it

has not, she has no fever. This is the first MRSA infection in Ward 17 for 46

days, and she has been in for 44. The treatment is a combination of

antibiotics, intravenous vancomycin (by peripherally inserted central

catheter) and oral rifampicin. This is the standard and best treatment for

MRSA.

This is Jo's third infection. The previous two, a urinary tract infection and an

e-coli infection of a smaller surgical wound, were treated successfully. There

are good chances that this infection will meet a similar fate.

One of the problems with the 2-week course of vancomycin-rifampicin

treatment is that rifampicin interferes with the action of the blood thinning

agent Warfarin. Jo is on a 6-month course of warfarin to avoid any further

blood clots. After some discussion about whether to choose a (weaker) single

drug treatment for the infection (that is not to use rifampicin) it was decided

instead to stop using Warfarin. For the coming two weeks Jo's blood thinning

will be delivered by injections of another blood thinning agent, fragmin.

If you visit Jo, you must now scrub your hands using an antimicrobial agent,

the red one at the hand-basin in her room. It doesn't hurt. All of the visitors

in the last little while have been so welcome, with their blessings and

encouragement and compassion and gifts.

(Day 45, Sunday, Oct 5, 2008) A curious incident yesterday. It happened late

in the visiting day, about 7 pm, by force of circumstance.

We went for a second wheelchair jaunt. The planned route was a roll down a

secret back corridor to the staff canteen, a little sit there, then up in a lift and

along out the front door of the hospital, for some real fresh air, then finally

back to the ward via the hospital corridor which contains its very interesting

art collection ("it’s like an art gallery, but a little less so").

Jo was tired and weak and slightly nauseous, all of this attributable to the

antibiotics. When we got to within 30 yards of the hospital front door, she

called a stop and asked to be taken back to her room. She admitted that she

was afraid to go outside (it seemed so big, and last time she was outside ...),

that she really only felt safe in her bed (thus not on the commode, in the

shower, in her room chair, in her wheel chair, on a trolley), and that she had

not really confronted properly what happened 45 days ago on the pier.

Having got back to a single room I think Jo shelved the plan to talk to a

clinical psychologist, but she has now resurrected that plan. We shall persist,

quietly, slowly.

(Day 47, Tuesday, Oct 7, 2008, AM) Jo's situation is extremely difficult. Her

left foot is terribly swollen and screamingly painful, her left leg has many

blisters. She has decided to (try to) stop being teary and to start getting

angry.

She has five main questions to put to the surgical and pain management

teams today.

First, why is the foot swollen, and if it is protein deficiency as conjected, what

is being done about it? (She was promised a resumption of the high protein

drinks on Saturday. It hasn't happened, her appetite is very poor, and she is

nauseous)

Second, why is her pain relief not working, and what happened to the pain

management team's declaration four weeks ago that pain is unnecessary?

She has been given advice by a certain member of the nursing staff that is

tantamount to "this is orthopaedics, pain is inevitable, put up with it".

Third, are the sores fracture blisters (as conjected rather flippantly by the

same nurse), and if not what are they? If they are fracture blisters why have

they occurred more than 45 days after the fracture?

Fourth, why has the ward not got stocks of the two antibiotics (six hours late

yesterday with the rifampicin, late this morning with the vancomycin, in both

cases because the Ward had none of it)?

Fifth, what happened to the undertaking that the phlebotomists would no

longer take blood samples, and that the surgical team would take them

through the PICC line? The phlebotomoists keep coming, and they aren't

allowed to use the PICC line.

Jo is due to have her catheter removed today (yes I know it’s been coming for

a long time). She is going to refuse that procedure until the above are

resolved satisfactorily. Moving hurts, and she is weakened. The idea that she

can get out of bed regularly is just a nonsense, and in any case the nursing

cover is too weak to permit that. She was on the phone to me for ten minutes

this morning. During all of the ten minutes, her call to the nursing station

went unanswered.

In the face of all these things, wheelchairs, physiotherapy and chit chats with

psychologists are simply irrelevant.

Finally, I have to tell you I am increasingly horrified at the lack of

communication, not to me, to Jo. She is on heavy doses of vancomycin,

rifampicin and fragmin. Other than nephrotoxicity and hepatotoxicity, no-one

has detailed the likely and well known side-effects. She has learned more

from me than from the health care professionals. That is just mental.

(Day 47, Tuesday, Oct 7, 2008, PM) Anger works, to a degree, and we have

some resolution. I thought you might want to know how we went on the five

questions. When there is no resolution, I stay silent. Please excuse the

interpolation of some of my previous message:-

…

Second, why is her pain relief not working, and what happened to the pain

management team's declaration four weeks ago that pain is unnecessary?

She has been given advice by a certain member of the nursing staff that is

tantamount to "this is orthopaedics, pain is inevitable, put up with it".

The swelling is the cause of the pain. The attempted solution is elevation of

the limb, and increased doses of the longer-term sciatic pain relief medication

(gabapentin, the “nerve blocker”). The opiates will not affect the swelling

pain. The problem which this brings is that it is the gabapentin which causes

the hallucinations, and more gabapentin means more hallucinations.

Third, are the sores fracture blisters (as conjected rather flippantly by the

same nurse), and if not what are they? If they are fracture blisters why have

they occurred more than 45 days after the fracture?

They are not fracture blisters, they are caused by the foot swelling. The idiot

nurse (I could use stronger words) was in the room when this diagnosis was

delivered by the consultant surgeon. Jo's trust in this nurse is utterly broken.

Fourth, why has the ward not got stocks of the two antibiotics (six hours late

yesterday with the rifampicin, late this morning with the vancomycin, in both

cases because the Ward had none of it)?

Various bank holiday excuses were offered. I have no confidence that things

will be better, but the nurses have been humiliated, which achieves

something perhaps.

Fifth, what happened to the undertaking that the phlebotomists would no

longer take blood samples, and that the surgical team would take them

through the PICC line? The phlebotomoists keep coming, and they aren't

allowed to use the PICC line.

The undertaking has been restated.

(Day 50, Friday, Oct 10, 2008) The progress in the last couple of days has

been extremely pleasing. Jo is half way through the two week course of

treatment for MRSA. She seems to have become much less subject to nausea,

so that she had three good square meals, kept it all down, and had a cup of

tea and some toast as well. This is such great news, and Jo looks much less

grey in consequence.

The further news on the MRSA is that swabs of her skin tested positive for

the bug, so that for the coming week she must bathe daily in the same pretty

harsh antimicrobial agent which visitors to her room use for hand-washing.

Overall, though we will not have the MRSA all-clear for a further week or

more, but it would seem that age, resilience and a powerful constitution are

all on her side.

Despite some continuing bad left leg pain, and the weakness which the

antibiotics and limited food intake have caused, Jo has been performing very

well in physio all this week. All of the maneuvers which she practices are

becoming smoother and easier. She can walk further than before, though she

is still confined to using one leg. In a week, she will have permission to put

weight on her left leg as well, and then the objective is to walk properly

again. Yesterday, Jo managed to change her own clothes unassisted, for the

first time since admission, a great step on the path to independence.

Jo had a useful conversation with a clinical psychologist. I won't labour the

details, but clearly Jo has been through a major physical trauma, and it

would be odd if this did not carry some emotional consequences. Fortunately,

the psychologist’s diagnosis is that Jo is not suffering from post-traumatic

stress disorder.

The plan for the immediate future is to make another assault on getting

outdoors, weather permitting, this weekend.

(Day 51, Saturday, Oct 11, 2008) She overcomes, again.

She got into the wheelchair, without professional assistance, though there

was a gifted amateur knocking about. Then off, on trip number 3, to the staff

cafeteria, for a sit and a chat. On then to the main concourse, where she

bought a bottle of water, and a lovely fruit salad to augment breakfast. Down

the main concourse, to the front door, through it, and across to the "fresh air

garden".

Jo enjoyed smelling the roses, and running her hands through the lavender.

Mostly, she enjoyed the air. There is much to be said for recycling, but not

when it comes to air.

Inside again, a spot of window-shopping at the shoe shop, an inspection of the

floor plan of the hospital (so orienting), of an enormous wall tapestry, of the

view into her window from the adjacent corridor. Then to Ward 17, to bed

(with the pros taking note but no part). It was splendid, a triumph.

The five-day course of daily anti-MRSA antimicrobial washing is proving

difficult. The wash dries the skin, Jo may not use moisturiser, nor any

soothing cream, and the nurses would describe its impact on the burst leg

blisters as "nippy", which is nurse-speak for "hurts like hell".

The five-day course has two days to run. Hannah, a nursing assistant who

has benefitted from Jo's relationship counselling and travel advice, is to

make a small repayment on Tuesday, by giving Jo the Ninewells Hospital

equivalent of a spa day, with leg-shaving and a lavishing of unguents. "God, I

am looking forward to it", is an exact quote, from Jo, not Hannah.

(Day 53, Monday, Oct 13, 2008) Lola the stuffed panda, who has been a

comfort and support for Jo for seven weeks, appears to have been kidnapped.

She has been a rich source of banter with nurses and porters and cleaners;

the subject of remarkable human contact with Ninewells catering about

bamboo shoots, Szechuan yams, yak's milk, and human food as well; the only

panda in Ninewells history to have had troosers and a hat, the only one to

have been great with cub.

It seems Lola was swept up with bedclothes and transported for panda

laundering this morning. Grave fears are held. By magical symmetry, some

abhorring of a panda vacuum, a new panda appeared last evening, less loved

but no less loveable.

(Day 55, Wednesday, Oct 15, 2008) Lola was lost and now is found. Jo was

very upset about Lola, and the staff were not derisive, they understood her

function and importance. Then yesterday morning the laundry found her and

rang the Ward. They woke Jo and told her. It was very nice, so now she has a

Lola and a Brigit.

Jo is getting stronger. Her left leg is still swollen and the pain is still bad, but

she is finishing today with the MRSA treatment, and I so hope we will get the

results of the lab work back by Friday. I’m confident she's beaten it, but we'll

see.

(Day 56, Thursday, Oct 16, 2008) She beats MRSA.

Rehabilitation

(Day 57, Friday, Oct 17, 2008) This week, in addition to the Joy of defeating

MRSA, Jo had a scan. The results of the scan are summarised in two words

in her file, "good union". They are two great words. It means her left leg is

recovering. Today she walked, rather than shimmied, 33 yards, with the

gutter frame. Good union to you all (might become my new greeting)

(Day 58, Saturday, Oct 18, 2008) Jo’s daughter and son-in-law visited. I got

the senior charge nurse to give me Jo's scans and x-rays, from her 13 (!!)

sessions of radiography. Then, using the room window as a light box, Kat

gave us a brilliant 45 minute impromptu lecture on Jo's progress and

treatment. It was just fantastic for Jo, so mentally helpful, for her to hear

and to see that her recovery has been massive, that it continues.

(Day 60, Mon, Oct 20, 2008, AM) Last night, for the first time in 60 nights, Jo

slept on her side, rather than on her back. When she woke she was surprised

to find herself so, and had to call for a nurse to help her roll. But that

detracts not one whit from the novelty and comfort.

(Day 60, Mon, Oct 20, 2008, PM) There have been times when it has been

necessary to be measured in response to good news. This is not one of them.

Today Jo walked 75 yards, with her gutter frame, a complete circuit of the

Ward, a lap of honour. She also walked back and forward in her hospital

room with a (lower) zimmer frame. Despite the defeated MRSA, and the

continuing horrid leg pain, she is way ahead of every prediction of recovery

and release.

Causation is so hard to discern, because one life is not an experiment. But I

attribute her miraculous progress to three factors. The first is ferocious

determination. The second is the tonic provided by the visits of her brother

David, and her daughter Kat and her son-in-law Noah. The third is the

buttressing provided by all her visitors, and correspondents, everyone who

has found a way to reach out and help her rise up.

It is worth recounting part of the visit of the daughter and son-in-law. When

her daughter last saw her, Jo was confronting surgery, with terrible risks,

flat on her back, filled with morphine. This time, Jo was standing, for a

standing hug, with the gutter frame pushed aside. It was majestic.

She is moving from Ninewells hospital to The Forgan Ward at St Andrews

Memorial Hospital, in 40 hours. Early on Wednesday morning, two sleeps

from now, she will be half way home. She is ebullient. Tomorrow there will be

a picnic of celebration in consequence, held somewhere in or near Ninewells

hospital. This is a consequence of her great progress. I will let you know the

visiting hours at St Andrews when I know them.

On Wednesday she will walk out of Ninewells hospital. I quote pretty much

exactly, "I rolled in here, I'm not going to roll out of here". We have been

humming away to each other these past 60 days "she shall overcome", but the

tense and the terms are just wrong. She overcomes.

(Day 61, Tuesday, Oct 21, 2008) I wanted to record and transmit two wee

things.

The first is the rate of progress in rehabilitation, objectively measurable by

distance covered in the past four sessions, using the gutter frame. The four

measures, in yards, are 10, 33, 75, 108.

The second is the menu of the celebratory Ninewells departing picnic which

Jo enjoyed in the staff cafeteria today, it being too windy for an outdoors

picnic: baked ham, coronation chicken, German peppered salami, pickled

herring, welsh cheddar, Dr. Floyd rolls, coleslaw, tomatoes on the vine, apple

pie. Passing staff regarded their lunch as poor by comparison.

(Day 62, Wed, Oct 22, 2008) (this dictated by phone) “As I said I would, I

walked out of Ninewells Hospital today. It wasn't just a symbolic two steps

over the threshhold, I walked all the way to the waiting ambulance. I do not

say this with any hint of smugness. It is just a record of a significant

moment. Nine weeks ago I said I would walk out of Ninewells, and today I

did.

The Journey was lovely, if a bit bumpy! The Tay was silvery.

I am in The Forgan Ward at St Andrews Memorial Hospital, for the now.

Visiting hours are 2-8. Supper is served about 5, and therefore visitors are

not encouraged between 5 and 6, but there is no ban. It would be delightful to

see people. If the weather is fine, there is a pretty garden to sit in

love

Jo”

(Day 70, Thursday, Oct 30, 2008) Jo made a special guest appearance today

at the Byre Theatre, in the role of "a coffee drinker". She lingered, so glad to

be away from hospital, only driven out eventually by loud bad piano playing.

She will return there, certainly for lunch or dinner, maybe for drama. The

wheelchair-bound get the best seats in the theatre, and rightly so.

Wheelchairs are plain hard honest work.

The new location has some few attractions, a lovely little garden, and

particularly the gym in which Jo has her physiotherapy. The new

physiotherapist now has a good understanding of the patient, delivered in

one dramatic incident, with Jo on the parallel bars. "OK, rest after this one",

the physio said. Jo replied "I'll rest when I get it right", which she then did.

Jo is desperate to get out of hospital.

But the second cousin of desperation is corrosive despair, and the reality is

that Jo has been experiencing a deal of that too. She has been trying so hard

but feels she is progressing so slowly. When the correlation between effort

and outcome is broken, laboratory rats become confused, despondent,

diffident. Humans have that tendency too, but can rise above it, by

recognising it, and so Jo shall.

St Andrews Memorial is a small "cottage" hospital (on Abbey Walk, visiting

hours 2-8), and one consequence is that the range of food choice is narrower.

But, inspired by the telling example of Clare Priest, Jo's diet has been

supplemented with fresh raw fruit and vegetables, and other similar treats of

cheeses and olives and breads and sweetmeats.

I am leery of causing offence, but will gladly do so in pursuit of recovery. Jo

doesn't crave or need sugar-based products. She has no use for flowers. It is

dietary variety and protein, and good company and sparkling conversation,

that help her rise up again.

(Day 72, Saturday, Nov 1, 2008) I sat in on Jo's physiotherapy again. Her left

leg improves: left-to-right movement is better, up to perhaps 25 degrees; knee

flexibility is also greater so that the thigh can move to perhaps a 60 degree

angle to the bed, with assistance. And, for the first time, at the parallel bars,

she stepped, on to a mini-step, about one third the height of a real riser. She

learned the excellent if theological mantra "good up, bad down": the good

right leg leads in a step up; the bad left leg leads in a step down.

The physiotherapy is painful, and Jo was teary afterwards, though Jo is as

ferociously determined in remaining positive and upbeat as she is ferociously

determined in her physio. It is impressive to watch. The teariness is harder

for Jo now that she is again on an open ward. I eased her tears with a

diprobase foot massage.

There are only three further substantive pieces of news.

The first is the physiotherpaist's response to Jo's question, "will I regain full

mobility, walking freely and without a limp?". The answer was "I don't

know".

The second is the Ward doctor's answer to Jo's question "when can I

reasonably expect to go home?". The answer was "four weeks", which takes us

to 100 days.

The third is Jo's INR, the measure of blood coagulation. It is up from 1.2 a

week ago to only 1.4, but the target range is 2-3. In consequence, as well as

the resumed course of oral Warfarin, the daily dosage of injected fragmin has

been raised. The injections hurt.

If the tone of this seems grim, then that's about right. But be assured that,

though she and I sometimes react in that way to all this hardship, I try so

hard to bring into the hospital only support, encouragement, laughter,

charisma. She was high-fived out of the gymnasium at the end of the physio

session.

(Day 76, Wednesday, Nov 5, 2008) I find myself setting all this to music. So I

have a little ditty, for countertenor and cat, to the tune of "When Johnny

comes marching home", which begins "The INR is 1.6, meow, meow", and

then proceeds to rhyme 1.6 with "fragmin pricks". Then there is "18 yards

and a two-thirds step" to the tune of Tom Waits' "Sixteen shells from a thirty-

ought six". But I resist these musical temptations.

Jo was thrilled that her football team (Spurs) finally won a game. I visited

the hospital that afternoon, then went to watch the game with our friend

Graeme, in a pub because it was on Setanta. Then we rushed back to the

hospital just before visiting ended, to give a breathless live match report.

Last night Graeme provided four magical texted match reports, live, during

the Man U - Celtic game, while I myself was away playing the pool of the

gods in a dump called Colinsburgh.

Jo's new physio is Lindsey (perhaps I should write several songs for a physio

girl band, Lindsey and the Lauras). She is tell, spare, strong. She now has Jo

working on a zimmer frame, which is lower than a gutter frame, and scarier

in consequence. She made 18 yards, twice, in the physio session I watched

yesterday. As well Jo has graduated from a one-third step to a two-thirds

step, two-thirds the height of a standard riser.

The health care professionals have been making some interesting

observations, and asking some interesting questions. The occupational

therapist observed Jo dress and wash, and was quite astonished at her

facility at both. The Ward doctor asked whether Jo or I could administer

fragmin injections on release. Jo said she was not sure if she could. I said I

could. These are promising portents.

Yesterday's hospital treat from me was tomatoes on the vine and a large tub

of sliced organic carrots, the day before some lovely ham and some mild

cheese. All this gets stored in the Ward fridge, in an oversized Tupperware

lunchbox I found. Today's treat will be my laptop, with a double dose. First, a

slideshow of photos of animals, children, art, friends. Then Obama's great

great acceptance speech as an mp3 file.

We have made some plans for wheelchair expeditions a little further afield,

but winter is closing in and we have done little more than runs for coffee to

the Byre Theatre, and one lovely expedition to the gardens of St Mary's

Quadrangle. But we have plans and dreams, and they are realistic ones.

(Day 77, Thursday, Nov 6, 2008) A day of inspiration, niggling, dazzling, rain.

Jo went to the hospital "day room", to watch a little slide show of beloved

children and friends and animals, to listen to the Obama speech,and to watch

Springsteen at the Cleveland Obama rally, singing (come on up to) The

Rising. It seemed apt.

The physio Lindsey continues to be dazzled by the patient's determination

and progress. The occupational therapist took Jo to the hospital kitchen, and

watched and assessed as Jo made toast and tea, a trivial challenge for such

an accomplished chef. Lindsey showed Jo a 1:1 scale plastic model of pelvis

and spine, and talked her through where each of the fractures were, and why

her left leg is still only PWB, partially-weight bearing. It was a revelation.

For the first time perhaps, Jo understood that her trauma has been

"massive".

There are niggling problems. Jo broke a tooth on a confectionery a while ago,

and tonight her dentist visited, professionally not socially. Some few of the co-

occupants of the Ward object to, perhaps envy, Jo's growing ability to read

and write into the night. Jo learned today, the fruit of previous endeavor, of

the existence and location of six file boxes of previously unknown

correspondence regarding (and in some cases by) the subject of the biography

she is writing. She is thrilled, champing to get to the boxes.

Before I left the hospital this evening, we went for a brief spin outside, and

there was a gentle misty Scottish rain. Picture this, two people, one sitting

one pushing, both faces upturned to accept the rain. Running late, I bolted for

the bus, but before I did, Jo said just three quick words. She said "yes we

can".

(Day 78, Friday, Nov 7, 2008) We now have a target release date, and it is 14

days hence, Friday November 21st, the 92nd day of Jo's hospitalisation.

Coming into the home straight, one out one back, and looking good.

(Day 80, Sunday, Nov 9, 2008) In place of the usual, this a brief letter to

Clare Priest, who gave Jo the gift of her first meal out of hospital in eighty

days.

"Dear Clare,

I thought that, as well as gratitude, you deserved a brief report.

We rolled to the New Inn. It was so great that Jo's smiling entrance elicited

smiles in return from just everyone in the bar - many people cannot bear eye

contact with those in wheelchairs, and we had clearly lucked upon a place

where that was not so. Jo ordered a steak with a pepper sauce, and with real

pub chips, and a nice side salad. I had the haddock. The food was splendid,

and demolished.

Given the failure of our little medically authorised experiment in the hospital

with wine, Jo had a soda and lime. So sensitised is she that she claimed to be

able to smell the bubbles in the soda, and I do not doubt it. But as well as the

food, there were the blessed circumstances. Any variation from the

unremitting constancy of the hospital Ward is a blessing.

There were people of all ages in the bar. There was a juke box playing. There

was football on the wall. There were young bar staff. There was the crack of

the pool balls. There were giggling children, and so a giggling she and me.

There was a loveable decrepit border collie slurping Guinness from a bowl.

It was a wonderful evening, if too brief.

Thank you

shane (for Jo)"

(Day 83, Wednesday, Nov 12, 2008) I witnessed another physiotherapy

session yesterday. Jo worked with an elbow crutch, walking forward and

backward, left arm on parallel bar, right arm supported by the crutch. Then

she stepped on and off a full sized step, left arm on bar and right on crutch

again.

(Day 86, Saturday, Nov 15, 2008) (to the rhythm of a tune by Sir Mixalot,

which has the line "... and I cannot lie") She walks up stairs. She walks up

stairs, in the hospital gym. Four stairs, twelve moves, one elbow crutch, much

effort.

The difficulty in being determined is that you must always be determined,

which is wearing. And I cannot lie, the Forgan Ward of St Andrews Memorial

Hospital is not stimulating. It has an average patient age of Jo's dearly

departed mum. David, Jo's brother, sent her two CDs of performance and

chat, a desert island disc selection, and they have been intelligent company

and lovely distraction, which she misses so.

Jo has found herself seeing herself in the nonagenarians and centenarians in

the Ward. A nurse named Mo, which rhymes with Jo, had the ideal solution.

"Try seeing yourself in us", and by "us" Mo meant us nurses, and they are

vibrant. It is inspired advice.

This is the last lap of hospitalisation, and harder for that reason, so I'll say

this very plainly, very bluntly. If you can visit, do.

(Day 88, Tuesday, Nov 18, 2008) There are two physiotherapy objectives this

week. The first is to scale twenty stairs, which return home requires. The

second is to walk with a pair of elbow crutches. Though it is only Monday,

today she has achieved the second objective. She walked around the hospital

gymnasium, no frame nor bar nor wheels.

(Day 90, Thursday, Nov 20, 2008) She scales 21 steps with an elbow crutch.

Release

(Day 95, Monday, Nov 24, 2008) On Friday, the NHS delivered various pieces

of therapeutic equipment and furniture to Jo's flat. It made for a delightful

weekend for Jo's cat Isla, for the deliveries were bubble wrapped, and Isla

has feline plastic fetish syndrome. Isla was equally delighted to help the

occupational therapist who visited this morning, to unwrap, adjust, install

the equipment. The therapist declared the flat ready and the cat lovely.

This afternoon was bitterly cold, but bright and still, in St Andrews. We went

for a rolling stroll, intending to view the surf from the East Sands, but

roadworks and enormous gutters and impassably steep roads conspired to

throw us north, toward the harbour and the pier. At every step Jo knew she

had the opportunity to turn back or away, but she did not. She sat for a little

while, wheelchair brakes on hard, not four feet from where she fell, and had a

little cry. "I am so lucky to be alive", she said later. It was her first visit to the

pier since her fall; I suspect it will be her last. It was an act of valour, of

honest spontaneous confrontation.

This morning, Jo learned that, three sleeps from now, on Thursday, two days

shy of a century of days of hospitalisation, she will be released. Thursday is

Thanksgiving in America, and now too in Scotland. This therefore will be my

last update on Jo's behalf. If there is more to be said, Jo will say it herself.

Endnote

(Day 98, Thursday, Nov 27, 2008) Today is Thanksgiving, and with great Joy,

because at last I am at home, I rather than Shane am writing this update to

you all.

It has often struck me that the two little words “thank you” are asked to

carry more weight than they are designed for, but I want to start by thanking

all of you who have been following Shane’s e-mails and responding by sending

me such kind and uplifting messages of support. I can tell you that every

good wish has been forwarded to me, and each kind message has lifted me up.

So, thank you.

Shane’s emails have obviously and necessarily been about me: my accident

and my recovery, but they only tell half the tale. Shane has rarely mentioned

himself, nor his part in my recovery and rehabilitation, and it’s time that was

put right.

As you can imagine my recollections of the early days are sketchy and may

well be entirely inaccurate. I am now fully qualified to give expert testimony

on the effects of morphine, and a clear grasp on reality is not one of them.

However, what I recollect with absolute certainty is that Shane was there. He

was there constantly, he was there when I fell asleep, and when my

nightmares woke me up. He was there to massage my feet, which eased me

when every other part of my body hurt. He was there when doctors told me

stuff I needed to know, but couldn’t make sense of – it’s hard to make sense of

anything when you lose the thread after the first word of the sentence. He

was there beside me in ICU, my lifeline to reality among the beeping

machines and silently shod nurses moving like wraiths in the semi-darkness.

He sat beside me and read to me in his beautiful melodic voice, the only thing

in that shrunken painful world that I wanted to keep me from blessed sleep.

Shane was there every day, despite the fact that he does not drive, and to get

from Anstruther to Ninewells Hospital in Dundee requires three buses and

much waiting in between – both ways. There were days when he spent more

time travelling than visiting, and on the day Lola was lost he bought me a

replacement on his way out which meant he missed his bus. Unfortunately it

was a Sunday. It took him four hours to get home.

Shane was there at exactly 3 pm on the momentous afternoon I stood up for

the first time, he walked through the door just as Laura, Laura and Laura

were preparing, and became an honorary Laura so he could take hold of my

right arm (the unbroken one) and lock his eyes with mine. It was his faith

that enabled me to stand on my own two feet for the first time since the

accident.

Even when Shane wasn’t there in person, he found ways to improve the

quality of my life. Hospital rooms are functional, so little attention is paid to

the décor. My room had cream walls, a huge clock immediately opposite my

bed, and a large window to my right through which I could see another part

of the hospital. It was like Hitchcock’s “Rear Window”, though Jimmy

Stewart only had a broken leg, the wuss. Shane brought me in his

reproduction of Van Gogh’s “Bedroom at Arles” which was propped on a

footstool in the corner of Jo’s “Bedroom at Dundee”. It gave me so much

pleasure to have something so very beautiful to look upon. Every nurse who

came into my room commented upon it and asked me about it. When I said

that Shane had brought it in, one of them asked if he has painted it himself, a

compliment I couldn’t wait to share with him. While my life was a routine of

meals, drugs and medical procedures, all of which involved people, Shane’s

routine was very different. I was not the only one who fell off the pier.

Shane’s life has been on hold since August 22nd, and apart from visits with

me, he has been pretty much alone except for my cat. Shane’s e-mails present

me as some kind of heroine. This is impossibly untrue. It is well known that

superheroes have a strange fashion sense and seem, regardless of gender, to

wear their underwear over their outerwear. This was made impossible for me

in Ninewells as, first they cut off my outerwear, my last pair of jeans, and

later my underwear went the same way. Superheroes do not customarily

wear hospital gowns. The gap down the back is not a very heroic look. I wore

a hospital gown for several weeks. So be in no doubt I am not a heroine. I

have simply done what I had to do to get better. Many of you have been kind

enough to applaud me for my strength and call me inspirational, but I am not

strong, I feel small and frightened most of the time. It is Shane who gives me

my strength, and Shane is the inspirational person in this tale. I do not seek

to preach, but we should all strive to have his selflessness, his constancy and

his kindness.

But most important of all, for nearly one hundred days Shane has had the

sole care of my cat. However, I have to report that Shane cannot be granted

full superhero status as he has turned my lively Isla into a corpulent kitty.

Apparently, each time she meows he responds with biscuits. She meows a lot

more than she used to.

I began by thanking all of you, but I want to end by thanking Shane. It’s been

98 days since my accident. I came home today, and walked up the 20 steps to

my flat, using elbow crutches. I cannot say with any certainty, morphine or

not, what my recovery would have been like without Shane. But I know with

absolute certainty that without Shane I would not be home today, so my

special thanks on this momentous day are devoted to my hero, Shane Bonetti.

Jo (for Shane)